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                                      What It Means to Be a CIC - The Certified Insurance Counselor (CIC) designation is a distinction that represents a commitment to professional excellence and leadership within the insurance industry. The 28,000+ designated CICs across the country are recognized as among the best and most knowledgeable insurance practitioners in the nation. The formal training required to become a CIC includes 100 classroom hours and the successful completion of five comprehensive exams, with an annual update required to ensure that CICs maintain their edge as the most capable and current insurance practitioners in the industry.  

    Physician's Online Medical Malpractice Insurance Quick Price Indication Request

                                                                     

To Get A Quick Medical Malpractice Pricing Indication With Several Leading Property & Casualty Insurance Companines Complete The Below Online Application

 

Physician's Medical Malpractice Liability Insurance Companies We Offer

Insurance Company Name

Insurance Company Name

ACE (USA and Bermuda)

Lloyds of London (and all syndicates)

American Reinsurance

 Medical Protective
Berkshire Hathaway

National Fire and Marine
Certain Underwriters at Lloyds ProAssurance
Evanston (Markel/Shand)

Red Mountain
General Star RSUI (Landmark)
Hudson  
 

With The Following Basic Information Several Of Our Insurance Companies

May Provide An Annual Rate Indication For Your Consideration By Email Or Fax

Who is applying for coverage?
 

Select the type of coverage needed from the following:
 
 
Individual only: (Including Physicians/Dentists or Other HealthCare Providers joining an existing Medical Protective insured Group).
For further assistance, to determine if your application can be submitted online, please contact your agent, who may be found on the Home page - About Us - Find your agent.
 
Individual and Entity (Available for Physicians and Dentists requesting coverage for themselves AND their Solo Corporations simultaneously. Note: To qualify for Solo Corporation coverage, individual Physician or Dentist has to be a Shareholder or Partner in the Solo Incorporation, should not have other shareholder, partner, employee or contracting Physicians or Dentists, can have Other Health Care Providers that are sharing limits with the Entity. If you do have other shareholder, partner, employee or contracting Physicians or Dentists within your corporation or partnership, please see the "Group" note below.)
 
Entity only: Available to currently insured Medical Protective Individual Physician or Dental customers who are either a Shareholder or Partner of the Corporation or Partnership (should not have other shareholder, partner, employee or contracting Physicians or Dentists, can have Other Health Care Providers that are sharing limits with the Entity). If you do have other shareholder, partner, employee or contracting Physicians or Dentists within your corporation or partnership, please see the "Group" note below.

Select one of the following two for Entity coverage:
 
Separate Corporate Limits: Enter the policy number of the Physician or Dentist: :
Corporation or Partnership sharing limits with current insured's individual policy: You will need to contact your Agent or a Customer Service Representative at The Medical Protective Company to modify your individual policy through an adjustment.

Group: Available to all individuals who are currently insured or requesting coverage from The Medical Protective Company . Note: Please us for further assistance to  to discuss this large group coverage program.

 

 

 

 General Information

Please enter your highest risk practice location, if the applicant or corporation has multiple practice locations.
 
* Required Fields.  
 
Individual Applicants :
  *First name:
  *Last name:
  *Preferred Method Of Contact: Phone      Email       Fax
  *Telephone Phone #:
  *Cell Phone #:
  *Best Time To Call:
  *E-mail Address:
  *Fax Phone #
  *Practice - Street Address
  *Practice - City
  *Practice - State:
  *Practice - Zip Code
  *Practice County:
 
  *Degree:
  *Specialty:
  *Surgical Procedures You Provide
  *Policy Type:
  * Requested Effective Date : (mm/dd/yyyy):
 		 / /
   
  *Current Malpractice Insurance Company
  *Date 1st Insured By Current Insurer / /
  *Current Policy Expiration Date (mm/dd/yyyy): / /
  * Malpractice Liability Insurance Limits:

If Other Specify

  Are you joining a group currently insured by the Medical Protective Company? Yes   No  
   If Yes, Please enter the Group Number:
 
  *Hours You Work Per Week:
   * Graduation Date (mm/dd/yyyy): / /
   * Residency End Date (mm/dd/yyyy): / /
   * Number of Claims:
   * Total Claims Paid: $
   * Last Claim Date (mm/dd/yyyy): / /

Comments:
 

If you would prefer to complete a full application to obtain a bindable quote download & complete one of the following forms:

 PHYSICIAN'S MEDICAL MALPRACTICE APPLICATION

#

 Form Name

Description

 Click Image  Below

1.

 

MS WORD VERSION

 MAY BE COMPLETED ONLINE  -

 SAVED - PRINTED -

 FAXED OR EMAILED AS ATTACHMENT

 

Physician's Professional Liability Insurance Application
2.

ADOBE PDF VERSION

 MUST  BE  PRINTED - COMPLETED BY HAND

OR TYPE WRITER -

THEN FAXED

 

Physician's Professional Liability Insurance Application

 

 PDF

Download  Application Forms To Your System - Save -Complete Application - Save Your Data - Print - Email or Fax

  Email:  edhemphill@hemphillinsuranceagency.com   /  Fax:  (936) 448-1013