Inquiry Forms
List
CLICK
HERE
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.
|
