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MAG Mutual Insurance Agency, LLC

FFActs Physicians Regulatory Insurance Quote

Name of Organization: Phone: Fax: State Practicing in: AL FL GA NC SC TN VA Number of Physicians in Your Practice: Number of RNs, LPNs and Physician Assistants in the Practice?: Facility Location (Physical Street Address): City: State:    Zip: Contact Name: Contact Phone: Fax: Email Address:     Do you have this coverage now? Yes No Has your organization ever had a claim or investigation? Yes No If yes, please explain: 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 MAG Mutual Group of Companies without your express permission, or as required by law.