Healthcare Liability Consultants can provide an immediate review of your current professional liability insurance and provide you with a quote. To facilitate your request, we need to obtain necessary confidential information. Based on the answers provided, Healthcare Liability Consultants can provide you with either confirmation of your current insurance situation and/or carrier or we can present options that you may not have previously considered. All information gathered in this site remains confidential and subject to the Health Insurance and Accountability Act of 1996 (“HIPAA”).

Applicant Information
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Personal Information

*First name:
*Last name:
E-mail address:
   
Office street address:
City
*State
Zip
*County
   
*Phone
Fax
Office manager/contact person:
Year you first began practice:

Coverage Information

*What company are you currently insured with:
*Renewal Date:
Current type of coverage: claims-made occurrence
Current liability limits:
*Policy expiration date:
*Retroactive/prior acts date:

General Information

Do you practice as a: Solo practitioner Partnership LLC Solo corporation
*Specialty:
Surgery performed: (Check all that apply) Major surgery Minor surgery No surgery
*How many hours is your business open? Full time Less than 20 hours per week
Board certified? Yes No
*Any claims in the last ten years? Yes (enter how many) No
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