PREMIUM INDICATION


 

Practice Name:

First Name:

Last Name:

Address:

City:

County:

State:

Zipcode:

Email Address:

Telephone:

Fax:

Specialty:

Occurrence
or Claims Made:


Retroactive Date
(N/A if Occurrence):

Limits of Liability:

Coverage Effective Date:

Coverage Expiration Date:


Have you taken a risk management course
within the past three years?

Yes   No

Board Certified?

Yes   No

Do you practice part-time
(20 hours per week or less)?

Yes   No


Expiring or renewal premium?:



Please identify and explain any gaps in coverage:

Number of open claims:

Number of closed claims:

Total Paid or Settled Amount: