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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 Liability Coverage
    New-to-Practice Solo Physicians & Oral/Maxillofacial Surgeons

Note: At this time, we are only providing professional liability premium estimates in California and Delaware.

Fields in blue are required.
Your Name
E-mail Address
Website Address
Medical License #
Mailing Address
Street Address
City
State
ZIP
Phone
 
Current Carrier
If Other, please specify
 
Check One
I have never had a claim filed against me.
I have had a claim filed against me.
 
How Did You Hear
About SCPIE?
 
Check One
I don't have a position yet.
I already have found a position.
 
I expect to be working
If you are joining a group practice, select the Group Type, the Group Size and
enter the Group Name.
Check One
Newly formed group
Existing group
Group Size
Group Name
Practice Location
Same as Mailing Address
City
State
 
Effective Date to Begin Coverage / /
Medical Specialty
Secondary Specialty
(if applicable)
 
Still in Residency?
Yes
Yes and I am/will be moonlighting.
No — I have completed my residency.
 
Date Residency Completed/Expected Completion Date / /
 
Residency/Fellowship Completed at
 
If you completed your training program within the last 3 years,
1. Tell us the date you started seeing patients.
Practice Start Date / /
2. Do you want retroactive coverage?  Yes    No
Retroactive (“Nose”) coverage provides protection for claims first made against you after the effective date of coverage with The SCPIE Companies arising out of your acts or omissions prior to the effective date and after the retroactive date of such coverage. If you do not obtain “Nose” coverage, you will have no coverage from The SCPIE Companies for claims arising out of these acts or omissions. If you do not want retroactive coverage, simply check no in the question above.
Retroactive Date / /
 
Comment/Question