Account Representative / Referral Please select your account representative, or leave as "General Representative" if you do not have one: General Representative Carol McIsaac Donna Foster Judith Graham Kathy East Margaret Rosa Teresa Heupel Toni Peconi Referred By / To:

 

General Information Your Name: Your E-Mail Address: Primary Practice Address: City:   County:   State:   Zip:  Office Phone:   Office Fax: Date of Birth:   License Number:

 

Practice Information Check each that applies to your practice Individual Group Practice Partnership Professional Corporation Association Affiliation Other:

 

Current Professional Liability Coverage Current Insurance Carrier: Limits of liability: $ per claim       $ aggregate Effective Date: Premium: $ Retroactive Date:

 

Professional Information Occupation: Specialty: Practice Operates: Board Certified Full Time Part Time Yes No

 

Claims History This information is kept strictly confidential

Claim #1   Claim Status: Closed   Open Claimant Name:   Date of occurrence: Insurance Carrier:   Location of occurrence:  Allegations: Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #2   Claim Status: Closed   Open Claimant Name:   Date of occurrence: Insurance Carrier:   Location of occurrence:  Allegations: Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #3   Claim Status: Closed   Open Claimant Name:   Date of occurrence: Insurance Carrier:   Location of occurrence:  Allegations: Amount paid on your behalf: $   Amount reserved on behalf: $

 

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