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July 4, 2008 Brokers Only Search Site Map Links Employment Contact Us Home Insureds Only
If you are a chiropractor, podiatrist or healthcare facility and would like a premium estimate, please contact our Sales Department at
800/717-5333, or .
 
Premium Estimate Request
    Professional and Business Liability Coverage

Note: At this time, we are only providing professional and business liability premium estimates to medical groups and clinics in California and Delaware.

Fields in blue are required.
Office Manager Name
E-mail Address
Website Address
Mailing Address
Street Address
City
State
ZIP
Phone
 
Current Carrier
If Other, please specify
 
How Did You Hear
About SCPIE?
Group Name
 
Practice Location
Same as Mailing Address
City
State
 
Effective Date / /
Limits of Insurance
Comment/Question

In the next section, fill in information for up to 10 physicians. If you would like a premium estimate for more than 10 physicians in your group practice, please contact SCPIE's Sales Department at 800/717-5333 or sales@scpie.com.
Physician #1 Profile
Name
Medical License #
Limits of Insurance
Part-Time/Full-Time
Medical Specialty
Secondary Specialty
(if applicable)
 
This physician does not want retroactive coverage.
Retroactive Date / /
 
If this physician completed his/her training program within the last 3 years,
tell us the date the physician started seeing patients.
Practice Start Date / /
 
Comment/Question
Physician #2 Profile
Name
Medical License #
Limits of Insurance
Part-Time/Full-Time
Medical Specialty
Secondary Specialty
(if applicable)
 
This physician does not want retroactive coverage.
Retroactive Date / /
 
If this physician completed his/her training program within the last 3 years,
tell us the date the physician started seeing patients.
Practice Start Date / /
 
Comment/Question
Physician #3 Profile
Name
Medical License #
Limits of Insurance
Part-Time/Full-Time
Medical Specialty
Secondary Specialty
(if applicable)
 
This physician does not want retroactive coverage.
Retroactive Date / /
 
If this physician completed his/her training program within the last 3 years,
tell us the date the physician started seeing patients.
Practice Start Date / /
 
Comment/Question
Physician #4 Profile
Name
Medical License #
Limits of Insurance
Part-Time/Full-Time
Medical Specialty
Secondary Specialty
(if applicable)
 
This physician does not want retroactive coverage.
Retroactive Date / /
 
If this physician completed his/her training program within the last 3 years,
tell us the date the physician started seeing patients.
Practice Start Date / /
 
Comment/Question
Physician #5 Profile
Name
Medical License #
Limits of Insurance
Part-Time/Full-Time
Medical Specialty
Secondary Specialty
(if applicable)
 
This physician does not want retroactive coverage.
Retroactive Date / /
 
If this physician completed his/her training program within the last 3 years,
tell us the date the physician started seeing patients.
Practice Start Date / /
 
Comment/Question
Physician #6 Profile
Name
Medical License #
Limits of Insurance
Part-Time/Full-Time
Medical Specialty
Secondary Specialty
(if applicable)
 
This physician does not want retroactive coverage.
Retroactive Date /