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Professional Liability Insurance

In order to receive a premium estimate, MAG Mutual Insurance Company asks to receive the request for the premium estimate 45 days in advance of the expiration date of your current policy. Also, MAG Mutual Insurance Company has relatively strict underwriting guidelines and we urge you to allow 30 days to complete the underwriting process. Note: This is not an application for coverage. This is a request for a premium estimate. Please enter your information for a non-binding premium indication. We are currently offering estimates for practices only in the following states:   AL, FL, GA, NC, SC, TN, VA Contact Information Contact Name: Applicant Name: Organization: Mailing Address: City:    State:    Zip: Phone:   Fax: Email Address: 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 Please tell us about your current insurance policy... Current Insurance Carrier: Policy Expiration Date: Physician Limits: Organization Limits: Yes No Does your current policy provide a separate limit of liability for your organization? Brief description of your request: Please tell us more about you... Specialty: Retro Date: Medical License Number: Primary State Practicing in: AL FL GA NC SC TN VA     If state is Florida, please select a county: AL Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Dade De Soto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Monroe Nassau Okaloosa Okeechobee Orange Osceloa Palm Beach Pasco Pinellas Polk Putnam St. Johns St. Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington # of Years Practicing Post- Residency or Fellowship, Without a Paid Claim: States Practiced in: Yes No Are you Board Certified by the American Board? If yes, what specialty? Yes No If not Board Certified, are you Board Eligible? If yes, when will you take the Boards? Yes No Has any insurer ever canceled, declined to issue or refused to renew your professional liability insurance, or offered insurance only on special terms, or have you been notified of such intent? If yes, please explain: Yes No Has any lawsuit ever been filed against you or have you been notified that any lawsuit will be filed against you alleging medical errors or omissions? If yes, please explain: Yes No Have any judgements been made against you, or any out-of-court settlements been made on your behalf, from an incident alleging medical errors or omissions? If yes, please explain: Yes No Have you ever been or are you currently under a State Board of Medical Examiners' Order? If yes, please explain: Yes No Have you been treated for alcoholism or drug addiction within the last five years? If yes, please explain: Information collected on this page will not be divulged or distributed to any individual or organization outside of MAG Mutual Insurance Company or the MAG Mutual Group of Companies without your express permission, or as required by law.