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Physician Quick Quote

Please use this Quick Quote form to submit your current info to Pennsylvania PRI, so that we may give you a fast estimate on coverage costs. Or, contact Nicole Lombardo, at 888-771-4762, ext. 257, email: n.lombardo@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 Pennsylvania PRI application will have to be filled out for an actual quote.