Premium Indication Request

Employment Practices Liability (available to current Physicians Insurance policyholders only)

Offered through Physicians Insurance Agency

(* indicates a required field)

Contact name:	*
Clinic or physician name:	*
Policy number:
Address:	*
City:	*
State:	*	Idaho Oregon Washington
Zip code:	*
Preferred contact phone number:	*
Fax:
E-Mail:
Desired effective date:	*
Desired limit:	*	$300,000/$300,000 Limit  $500,000/$500,000 Limit  $1,000,000/$1,000,000 Limit
Number of employees:	*	1-10 employees  11-20 employees  21-30 employees  31-40 employees  41-50 employees  51-60 employees  61-75 employees  More than 75 employees
Have you ever experienced an employment-related claim?	*	Yes  No

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