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Medical Practice Office Insurance - Quote Request

Please tell us about your current insurance policy... Current Insurance Carrier: Policy Expiration Date: Brief description of your request: Please tell us more about you... Specialty: State Practicing in: AL FL GA NC SC TN VA # of Physicians:         # of Employees:   Business Type:  Sole Proprietor      LLC      Partnership     MAG Mutual Professional Liability Insurance Insured?    Yes No # of Years in Business: I own my office building/condo: I lease my office space: Square footage: Square footage: Building/buildout value: Building/buildout value: Contents value: Contents value: Computer hardware: Computer hardware: Computer software: Computer software: The construction of the building I occupy is: Brick    Frame    Stucco   Concrete/Steel Years of Construction: # of Stories: Fire Sprinkler System: Yes No I am the only occupant of the building: Yes No List any loss/claim history for this type of insurance: 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 MagMutual Insurance Agency or the MagMutual Group of companies without your express permission, or as required by law.