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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Long Term Care - Proposal Request
Please complete the form below.

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Name: *
Clinic Name:  
Occupation/Specialty: *
 
Phone: *
Fax:  
E-Mail: *
 
Address: *
City: *
State: *
Zip code: *
 
Date of birth: *
 
Gender: *  Male
 Female
 
Smoker: *  Yes
 No
 
List any current medical problems:
 
List any medication now being taken:
 
Spouse or other name:  
Date of birth:  
 
Nursing Home Coverage

Daily benefit:
 $60
 $70
 $80
 $90
 $100
 $120
 $150
 $170
 $200
Other:  
 
Elimination period (waiting period):
 30 days
 90 days
 180 days
 
Benefit period (length of coverage):
 2 Years
 3 Years
 4 Years
 6 Years
 Lifetime
 
 
RIDERS

Home Health Care

Percentage of Nursing
Home Care:
   50%
 100%
 
Inflation (monthly benefit increases each year):    5% Simple
 5% Compound
 



Physicians Insurance - Hospital Liability ProtectionThe definitive choice for managing hospital risk.
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