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 Medical Malpractice Quote 
Form: Medical Malpractice Quote
Medical Malpractice Quote




Contact Information
First Name:
Last Name:
Daytime Telephone:
Evening Telephone:
Email:
Address:
City:
State:
Zip:
Practice Information
Location Address:
How Long At This Location:
Check each of the following that applies to your practice: Individual Group Practice Partnership
Professional Corporation Association
Affiliation Other:
Number of physicians in group 2-4 5-8 9+
If in a group practice, is the group owned, managed or controlled by any other healthcare entity? Yes No
If "yes", name the entity and the relationship:
Current insurance carrier
Limits of Liability: $ - $
Deductible: $
Renewal Date: / /
Premium: $
Per Quarter:$ or Annually: $
Retroactive Date:
My desired effective date for
Medical Malpractice insurance is
Desired limits
(Check all you want quotes for)		 $1,000,000 - $3,000,000
$2,000,000 - $4,000,000
$5,000,000
Other $ - $
Number of employed Physician Assistants/Nurse Practitioners
Physician/Surgeon Information
Specialty: Full Time Part Time
Years Experience in Specialty:
Years Practicing in Community:
Board Certified? Yes No
Any previous claims activity? Yes No
If yes, Doctor Name:
Date of Claim: / /
Patient Name:
Status: Open
Closed Claim
Settlement
Judgment
Dismissal
If Open, Reserve Amount: $
If Closed, Amount Paid: $
Defense Costs: $
Comments or Questions
Deliver quote via:
 E-Mail Fax Regular Mail Telephone
No coverage of any kind is bound or implied by submitting information via this online form
We value your privacy. Every precaution has been taken to insure your privacy and security. Our intent is to release information to you only. We will not provide your data to any third party or group for sales, marketing, or any other purposes. By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

By completing this form, you are acknowledging your understanding of and agreement with these terms

Coast West Insurance Agency, Inc. 28310 Roadside Dr. Ste 115 Agoura Hills, CA 91301 (800) 566-3331

© Coast West Insurance Agency, Inc., 2008



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