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? MailPhoneEmailFax (check all that apply) Have you spoken with a representative from our company?  YesNo If so, who? How did you hear about us? Web site / Search Engine Direct Mail Tradeshow Newspaper / Magazine MAG Mutual Employee Colleague Other   If other, please explain:

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