Physicians' Reciprocal Insurers

Chiropractor 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

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

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	Part-time

10. Comments:

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