SHORT FORM APPLICATION

Print out, complete, and fax to 772-562-9321 for a quote.

Physician Name _____________________________________________________________

Name of Corporation/Partnership Affiliation ________________________________________

Speciality__________________________________________________________________

Please indicate the percentage of your practice which includes the following (should total 100%)

_______% No Surgery -- other than incision of superficial abscesses or suturing of skin and superficial fascia, similar minor procedures encountered in a normal family-type practice.

_______% Minor Surgery -- includes above and general practitioners and specialties performing minor surgery or invasive procedures for diagnostic purposes or normal deliveries and assisting in major surgery on their own patients

_______% major Surgery -- includes above and general practitioners and specialties performing vasectomies, appendectomies, C-sections, tonsillectomies, adenoidectomies and assisting in major surgery on own patients or other than their own patients or who assist in major surgery on patients of others

Other Procedures Not Listed Above _______________________________________________

___________________________________________________________________________

Years in Practice ________ Years in Practice in Florida________Board Certified___Yes___No

Name of Current Professional Liability Carrier ________________________________________

Coverage Form: Claims-Made___________Retro Date____________Occurrence___________

Limits of Liability______________________________________________________________

Societal Memberships __________________________________________________________

Claims History

Have you ever been named in any professional liability claim or lawsuit? ____Yes____No

Note:  Any premium indication is subject to receipt and review and approval of a fully completed application by a company underwriter.  Rates are subject to rates, procedures and underwriting guidelines at time of application.

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