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CGA Medical Malpractice Premium Indicator
We would like to provide you with a free, no-obligation medical malpractice premium indicator. Please provide as much information possible for the most accurate premium. This information will be kept confidential and will be used for this purpose only..

Submitting Information
Business Name:
Contact Name:
Street Address:
City:   State:   ZIP:
County:   Email:
Business Phone: Fax:

General Information
Your Name:
Your E-Mail Address:
Primary Practice Address:
City:   County:    State:    Zip: 
Office Phone:   Office Fax:
Date of Birth:   License Number:

Practice Information
Check each that applies to your practice
Individual
Group Practice		 Partnership
Professional Corporation		 Association
Affiliation		 Other: 
 
 

 

Current Professional Liability Coverage
Current Insurance Carrier:
Limits of liability: $ per claim       $ aggregate
Effective Date:   Premium: $   Retroactive Date:

 

Physician/Surgeon Information
Specialty: Practice Operates: Board Certified
Full Time   Part Time Yes   No

 

Claims History
This information is kept strictly confidential

Claim #1   Claim Status: Closed   Open
Patient Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #2   Claim Status: Closed   Open
Patient Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #3   Claim Status: Closed   Open
Patient Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Amount paid on your behalf: $   Amount reserved on behalf: $

 

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


 

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