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Medical Professional Liability Insurance To receive a premium estimate please complete the following information in advance of the expiration date of your current policy. Please enter your information for a non-binding premium indication. We are currently offering estimates for practices in the following states:   AL, AR, FL, GA, KY, NC, SC, TN, VA   Please tell us about your current insurance policy... Current Insurance Carrier: Policy Expiration Date: *Remember: Underwriting may take up to 30 days. Physician Limits: Organization Limits: Yes No Does your current policy provide a separate limit of liability for your organization? Yes No Are you requesting Prior Acts coverage? Yes No Are you finishing residency or fellowship? Brief description of your request: Please tell us more about you... Specialty: Retro Date: Medical License Number: State Practicing in: AL FL GA NC SC TN VA # of Years Practicing 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: Applicant Name Contact Name: Organization: Address: City: State:    Zip: Phone: Fax: Email Address: How do you wish to be contacted? Mail Phone Email Fax 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 Information collected on this page will not be divulged or distributed to any individual or organization outside of MAG Mutual Insurance Company or the MagMutual Group of Companies without your express permission, or as required by law.