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Urgent Care Professional Liability

Urgent Care Professional Liability
NOTE: If more than one location, Please call (800) 723-5003 for appropriate forms
* Required Information

Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

First name:*
Last name:*
Address 1 (of Urgent Care Location)
Address 2
City:
State:
Zip code:*
Phone numbers:	Daytime:*
	Evening:
	Fax:
E-Mail address:*
Name of Facility

Type of Facility	Freestanding - Hospital Satellite Freestanding - Independent Other (Specify) :	Hospital - Based Physicians Office
Please Describe facility's scope of operations:
Are the services provided in this facility limited to a specific physician or medical group?	Yes No
If yes please identify the physician or medical group:

Current Insurance Company
Current Limits of Liability	Each Claim
	Aggregate
Desired Limits of Liability	Each Claim
	Aggregate
Last Annual Premium:
Requested Effective Date:
Current Coverage:	Claims Made* Occurrence
*Retroactive Date:
Have you ever been involved in a claim?	Yes No
Number of Open Claims
Number of Closed Claims
Amount Paid or Settled?
If Yes, please give dates and status:

Please contact me at a future date:
I would prefer to be contacted:	via email via telephone via fax in the mail
How did you hear about us?

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We respect your right to privacy and all personal information will be protected.