QUICK QUOTE FOR PROFESSIONAL HEALTHCARE SERVICES LIABILITY CLAIMS-MADE COVERAGE

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MAG Mutual Insurance Agency, LLC

QUICK QUOTE FOR PROFESSIONAL HEALTHCARE
SERVICES LIABILITY CLAIMS-MADE COVERAGE

For a free no-obligation quote fill out this form or call Chip Goen at 404-842-3311.

Name of Facility:
Phone:
Type of Facility (describe):
Facility Location:

City:	State: Zip:
Email Address:
Date you wish coverage to become effective:
Current retroactive date if any:
If no retroactive date, indicate “NONE” in space provided.

Limit of liability desired (Please check one of the following): $1M/$1M $1M/$3M $2M/$4M
a. Estimated gross receipts for next 12 months
b. Estimated patient visits for next 12 months

NOTE: If Imaging Facility: Complete breakout of annual gross receipts as follows:
X-Ray	MRI
CAT	PET:
Other:	(please indicate type)

NOTE: If Surgery Center:
Estimated total patient procedures for the next 12 months:

Visit = each separate visit to the facility; Gross receipts = annual gross receipts unadjusted; Procedure = each separate surgical step and or surgical act independent of the previous step or act.

Loss Information: Have any professional liability claims or lawsuits ever been made against your organization or its employees, contractors, owners or officers?
Yes No

Do you desire coverage for any employed allied healthcare professionals such as Nurse Anesthetist; CRNA; Physicians Assistant administering anesthesia; Pharmacist; Physician/Surgeon Assistant; Psychologist or Nurse Practitioner?
Yes No
If “YES” indicate number and type(s) of employees

How do you wish to be contacted? Mail Phone Email Fax
	(check all that apply)
Best time to be contacted during working hours?
Have you spoken with a representative from our company? Yes No
If so, who?
How did you hear about us?
If other, please explain:
	Requested information