Appointment – Trinity Physician Insurance

Medical Malpractice Insurance

Toll Free Call :

(877) 257-1619

Fill up the form to set a QUICK APPOINTMENT

1. First Name: *

2. Last Name: *

3. Medical Designation: *

4. Medical Specialty: *

5. Medical Sub-Specialty *

6. Are you ABMS American Board Certified? *

7. Do you practice Full Time or Part Time? *

8. Date of Birth: *

9. Primary practice location - street address: *

10. County, Parish or Borough that the practice is located in: *

11. City: *

12. State: *

13. Zip Code: *

14. Primary Contact Phone Number: *

15. Primary Contact Email Address: *

16. What best describes your medical practice setting? *

17. Do you or the medical practice have a registered legal entity such as a Corporation, LLC or Other? *

18. Name of Entity as it appears on your Articles of Incorporation (or input N/A): *

19. Are there any Ancillary Medical Staff EMPLOYEES or Independently CONTRACTED Medical Practitioners who will need to be insured under your Malpractice policy? *

20. Please provide your medical practice Web Site address:

21. Current Malpractice Insurer: *

22. How many CONTINUOUS years have you been insured by your CURRENT Malpractice Insurance Company? *

23. Current Malpractice Policy Expiration Date *

24. Current Malpractice Policy Retroactive Date: *

25. If you did not provide a Retroactive date does that mean you are on an Occurrence policy now? *

26. Limits of Liability that you are requesting: *

27. In the past 10 years have there been any times at which you were not actively practicing medicine or not actively insured or had ANY gaps in Malpractice Insurance Coverage? *

28. Have you experienced any CLAIM PAYOUTS or CLAIM SETTLEMENTS within the past 10 years? *

29. Are you or any member of your practice (for whom you have collaborative or supervisory responsibility) performing any of the items shown in PART 2 below? *

29. PART 2: *

Please provide any additional info or details regarding your practice or insurance needs here:

As applicant, please type in your full name here: *

Consent Agreement - your checkmark in the box means you agree. *

As applicant named above, I agree to allow this information to be used for the purpose of a pre-qualification quote analysis. I understand that the information I am providing may be shared with other parties but strictly and only for the purpose of determining Medical Professional Liability Insurance eligibility and preliminary pricing.

Please enter the date you completed and submitted the QUICK QUOTE form: *