Physicians Insurance, A Mutual Company
The premier provider of medical professional liability insurance for physicians,
other medical professionals, clinics, and hospitals in Washington, Oregon, and Idaho.

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Disability Business Overhead Expense - Questionnaire
Please complete the form below.

(* indicates a required field)



Contact name: *
Clinic Name:  
 
Incorporated?    Yes
 No
 
Phone: *
Fax:  
E-Mail: *
 
Address: *
City: *
State: *
Zip code: *
 
 
CURRENT OVERHEAD EXPENSE INSURANCE COVERAGE

Monthly overhead (not including physician's income): *
 
Elimination period (days):    30
 60
 90
 180
 
Benefit period:    12 months
 15 months
 24 months
 
 
SUPPLEMENTAL BENEFITS

 Future income option
 Residual (Partial)
 
Comments:
 



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