Med Mal Rate Indication Request (Print, complete & fax)

Physicians REQUEST FOR INFORMATION

Dennis Reynolds & Associates

PO Box 299 Netarts OR 97143

 

Phone: (503) 243-1880 or 503-780-5131
Fax : (877) 830-2950 (print out, complete form and fax back)

Website: www.DennisReynolds.com email: Dennis@DennisReynolds.com


Personal/General Information

Name: __________________________________________________________ MD DO

Practice Name: _________________________________________________________________________

Is this practice a (circle): Solo Solo PC Partnership LLC PC Other _____________________

Street Address (including building names and/or suite numbers):

__________________________________________________________________________________

City: _____________________________ State: _____________________ Zip: _________________

Phone: ( ) ________________________ Fax: ( ) __________________________

email address: __________________________________________________________________

How would you like to receive your indication? (circle) Phone or Fax or email __________________________

Do you have a practice/group/clinic administrator? _____ May we contact?______ (Mr./Ms.)_______________________________________________

 

Current Coverage Information

Specialty: _________________ Specialty Aspects (invasive/non-invasive, etc.):____________________

Malpractice Insurer: _______________________________________

Renewal date: _____________________________ Premium: $ _______________per_________________

 

Current liability limits: $__________________/ $____________________

Policy format: Claims-Made*_____ Occurrence _____

*Claims-Made Retroactive/Prior acts date (!) : ______________________

 

How many years have you been claim free? __________ If any claims, how many? __________

Date of last claim__________________

What year did you enter private practice? _________ Work 20 or less hrs/week? ____________________

COMMENTS: