Professional Liability
Fields marked (*) are mandatory.
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
Individual
Partnership
Association
Group Practice
Professional Corporation
Affiliation
Other
Current Professional Liability Coverage
Current Insurance Carrier
Limit of liability per claim ($)
Limit of liability aggregate ($)
Effective Date
Retroactive Date
Premium ($)
Professional Information
Occupation
Specialty
Practice Operates
Board Certified
Claims History (This information is kept strictly confidential)
Claim #1
Claim Status
Claimant Name
Date of occurrence
Insurance Carrier
Location of occurrence
Allegations
Amount paid on your behalf ($)
Amount reserved on behalf ($)
Claim #2
Claim Status
Claimant Name
Date of occurrence
Insurance Carrier
Location of occurrence
Allegations
Amount paid on your behalf ($)
Amount reserved on behalf ($)
Claim #3
Claim Status
Claimant Name
Date of occurrence
Insurance Carrier
Location of occurrence
Allegations
Amount paid on your behalf ($)
Amount reserved on behalf ($)
Additional Comments
Additional Comments