Premium Indication Request

Physicians and Surgeons Professional Liability

(* indicates a required field)

Name:	*
Address:	*
Preferred contact phone number:	*
Fax:
E-Mail:
Principal medical specialty or subspecialty in which you practice:	*
Clinic name:	*
Office practice location:	*
Street address:	*
City:	*
State:	*	Idaho Oregon Washington
Zip code:	*
Desired effective date:	*
Desired retroactive date (if applicable):
Your practice is:	*	Full-time  12 hours or less  13-22 hours  23-33 hours
Desired limits of liability:	*	$1,000,000/5,000,000  $2,000,000/6,000,000  $3,000,000/7,000,000  $4,000,000/8,000,000  $5,000,000/9,000,000
How many paramedical employees do you employ?
PA
ARNP
CNM
CRNA
Do you perform surgical procedures?	*	Yes  No

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