Physicians' Reciprocal Insurers

Physician Quick Quote

Please use this Quick Quote form to submit your current info to PRI, so that we may give you a fast estimate on coverage costs. Or, contact Christopher Curcio, Director of Sales & Marketing, at 800-632-6040, ext. 419, email: c.curcio@medmal.com

Fields with a * are required.

Please call me with premium information.

Please send me an application packet.

CONTACT INFORMATION

* Name:

* Address:

* City:	* State:	* Zip:

Contact Name:	* Telephone:	FAX:

* E-Mail:

PROFESSIONAL LIABILITY INSURANCE HISTORY

1. * Choose your specialty

Surgery

No Surgery

Minor Surgery

2. Choose the number of consecutive years with full malpractice insurance coverage without a claim paid in excess of $25,000 - $50,000

* County

* Full or Part-time

* Coverage

Years of continuous coverage immediately preceeding this year.

3. Your current license number

4. Do you employ any of the following? (please check)

Chiropractor	Nurse Anesthetist	Nurse Midwife
Nurse Practitioner	Physician's Assistant	Optometrist
Podiatrist

5. Expiration and Retroactive dates found on the cover page of your present policy

* Expiration	* Retroactive

6. Please list Medical Societies, IPA's or other Medical Group Affiliations to qualify for additional discounts:

7. * Please give me quotes on liability limits of:

$500,000 / $1,500,000

$1,000,000 / $3,000,000

8. * List your present insurance provider:

9. Discounts:	Risk Management Program	No Consent Option
	MagnaCare Member

10. Comments:

ALL QUOTES ARE ONLY AN ESTIMATE.
A PRI application will have to be filled out for an actual quote.