Mid States Insurance, Inc. - Medical Malpractice Quote

Medical Malpractice Quote

Contact Information

	First Name:
	Last Name:
	Daytime Telephone:
	Evening Telephone:
	Email:
	Address:
	City:
	State:
	Zip:

Practice Information

	Location Address:
	How Long At This Location:
	Check each of the following that applies to your practice:	Individual Group Practice Partnership Professional Corporation Association Affiliation Other:
	Number of physicians in group	2-4 5-8 9+
	If in a group practice, is the group owned, managed or controlled by any other healthcare entity?	Yes No If "yes", name the entity and the relationship:
	Current insurance carrier
	Limits of Liability:	$ - $
	Deductible:	$
	Renewal Date:	/ /
	Premium:	$ Per Quarter:$ or Annually: $
	Retroactive Date:
	My desired effective date for Medical Malpractice insurance is
	Desired limits (Check all you want quotes for)	$1,000,000 - $3,000,000 $2,000,000 - $4,000,000 $5,000,000 Other $ - $
	Number of employed Physician Assistants/Nurse Practitioners

Physician/Surgeon Information

Comments or Questions


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