Podiatry Plus Premier Podiatric Insurance Programs

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888-800-7239

Medical Malpractice Insurance Quote

We would like to provide you with a free, no-obligation medical malpractice insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

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General Information
Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:

Current Policy Information

Carrier:

Expiration Date:

Retroactive Date:

Type:

Claims Made Occurrence

Limits:

$100,000/$300,000
$1 Million/$3 Million

$250,000/$750,000
Other: $

Annual Premium:

Practice Profile

Date Practice Started:

Are you practicing as a:

Owner Employee Independent Contractor

# of Podiatrists in your practice:

Employees:

Independent Contractors:

Type of Practice::

Solo Partnership Corporation

# of hours worked per week:

Are you Board Certified?:

Yes No

Professional Organizations
to which you belong:

ACFAOM
APMS

ACFS
ABPS

AAFS
Others:

Risk Management Practices
Risk management course completed within the past 1 year?:	Yes No
If Yes, Date Completed:
Use of written informed consent for surgical procedures?:	Yes No

Patient Profile
What percentage of your practice involved diabetic patients?:
0-15% 16-30% 31-50% 51-70% 71-100%

Procedure Mix
In a calendar year, how many procedures do you perform that require General Anesthesia?:
Please indicate who administers general anesthesia including IV sedation:	I do MD/DO Anesthesiologist Nurse Anesthetist/CRNA Other:
What percentage of all your procedures requires Local Anesthesia?:	%

Loss Information

Please list any claims that were settled with payment to plaintiffs, or indicate "None": None

Year:	Details:	Claim Amount:
		$
		$
		$
		$
		$

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

One of the Midwest's largest privately owned insurance brokers, United Agencies has been writing Podiatric Malpractice Insurance for almost 20 years!

Phone: 888-800-7239 | Fax: 877-472-3007 | Email: medmal@uainc.com