Get an Indication - Physicians

If you are interested in getting a premium indication, please take a few minutes and fill in the form below. A Premium Group representative will follow up with you shortly.

Name
Birth date	Male Female
Phone
Fax
Email Address
Mailing Address
City
State	Zip:
County
Medical School
Graduation Year
Residency
Completion Date
Board Certified:	Yes No
Eligible:	Yes No
Specialty
Hours Worked per week


Hospital Affiliations:

Do you perform: (Please check all that apply)
	Invasive procedures other than incision of boils, removal of superficial lesions or suturing of skin?
	Needle Biopsy
	Colonoscopy
	Sigmoidoscopy
	Cosmetic Procedures
	Obstetrical deliveries
	Other special procedures -please list below:

Present Carrier:
Effective Date:
Retro Date:
Type of Coverage: Claims Made Occurrence
Limits of Liability
per occurrence annual aggregate

List all physicians, surgeon assistants, technicians, and nurses to be insured.
	None

Number of claims/suits open, closed, settled or dismissed during the past 10 years:

Do you have any knowledge or any pending claim or complaint against you or your employees which may give rise to a claim?
Yes No
If yes, has this claim been presented to the prior carrier?
Yes No
I authorize any physician, hospital, clinic, medical facility, medical society, and insurance or reinsurance company to release information necessary to evaluate this application. Furthermore, I understand that this is an application for an insurance quote, not an insurance binder or offer of coverage and that the insurance company will require additional information. Please digitally sign below.
Full Name, Title
The Premium Group, Inc. will use this confidential information for the sole purpose of requesting quotes from one or more medical professional liability insurance companies on your behalf.

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