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Professional Liability Quote Form
 









 

 

 

 

 

 

  

 

Contact Information
Your Name:
Primary Practice Address:
City:  
State:

  Zip:

Business Phone:   Fax:
E-mail Address:

Practice Information
Check each that applies to your practice
Individual
Group Practice
Partnership
Professional Corporation
Association
Affiliation
Other: 

Current Professional Liability Coverage
Current Insurance Carrier:
Limits of Liability: $ per claim       $ Aggregate
Effective Date:  
Retroactive Date:
Premium: $

Professional Information
Occupation:
Practice Operates:
Board Certified
Specialty:
 Full Time
Part Time 		Yes
No

About Your Business
Please give a complete description of your operations:

Claims History (This information is kept strictly confidential)
Claim #1
  Claim Status: Closed   Open
Claimant Name:
Date of occurrence:
Location of occurrence: 
Insurance Carrier:
Allegations:  
Amount paid on your behalf: $
Amount reserved on behalf: $
   
Claim #2
  Claim Status: Closed   Open
Claimant Name:
Date of occurrence:
Location of occurrence: 
Insurance Carrier:  
Allegations:
Amount paid on your behalf: $  
Amount reserved on behalf: $
   
Claim #3
  Claim Status: Closed   Open
Claimant Name:
Date of occurrence:
Location of occurrence: 
Insurance Carrier:  
Allegations:
Amount paid on your behalf: $
Amount reserved on behalf: $

Additional Comments


Please click the "Submit Quote" button to send your quote request.

This is a request for quotation only. No coverage is in effect until bound by an insurance carrier.

 

 

    
 
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The Zutz Group is licensed to provide Property and Casualty Insurance in all states except AK and HI.