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Inquiry Forms List

for a list of occupations that we are currently unable to write.

For a inquiry, please fax or mail the appropriate, completed form to us, attention Medical Malpractice Department. We will endeavor to fulfill inquiries within 48 business hours.

Please click here for a list of states we do business in.

Fax:  310.453.7971
Address:   P.O. Box 511
  Santa Monica, CA 90406

*These forms are in "pdf" format and require Adobe's Acrobat Reader in order to be read and printed. If you do not already have Acrobat Reader installed on your computer, please click on the Acrobat image to the right to download a free copy.

Physician Application
Nonstandard Physician Application

Healthcare Facilities Application

Medical Groups & Clinics Entity Application

Hospital Application

**Indications are estimates only and are based on the limited information provided. Any indication you receive from us in no way implies approval of coverage. Insurance carrier underwriting departments may require additional information and documents in order to provide an offer and bind coverage. They may require a completed application and questionnaire, a current declaration page and a company verified loss letter prior to approval.


Please make a
selection here

Phone 800.775.8642




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