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There is no obligation in filling out a quote request form, but you stand to gain insight into our competitive rates and mission-driven style of business. Please enter your information for a non-binding premium indication. A carrier representative will respond within 24 hours. Thank you!


*Required Items


Please tell us about your current insurance policy:

Current Insurance Carrier:
Policy Expiration Date:*

Remember, underwriting may take up to 30 days
Physician Limits:*
Corporate Limits:*
Yes No *

Does your current policy provide a separate limit of liability for your organization?

Please tell us more about you:

Specialty:*
Retroactive Date:*
Medical Licensing Number:
State Practicing In:
# of Years Practicing Post-Residency or Fellowship, Without a Paid Claim:
States Practiced In:
Yes No

Are you Board Certified by the American Board?
If yes, what specialty?
Yes No

If not Board Certified, are you Board Eligible?
If yes, when will you take the Boards?
Yes No

Has any insurer ever canceled, declined to issue or refused to renew your professional liability insurance, or offered insurance only on special terms, or have you been notified of such intent?
If yes, please explain:
Yes No

Has any lawsuit ever been filed against you or have you been notified that any lawsuit will be filed against you alleging medical errors or omissions?
If yes, please explain:
Yes No

Have any judgments been made against you, or any out-of-court settlements been made on your behalf, from an incident alleging medical errors or omissions?
If yes, please explain:
Yes No

Have you ever been or are you currently under a State Board of Medical Examiners' Order?
If yes, please explain:
Yes No

Have you been treated for alcoholism or drug addiction within the last five years?
If yes, please explain:

 

Physician Name:*
Contact Name:*
Corporation/Practice Name:*
Address:*
City, State, Zip:*
Phone:*  -   - 
Fax:*  -   - 
Email Address:*
How do you wish to be contacted? (check all that apply): Mail Phone Email Fax
 

*Required Items


Information collected on this page will not be divulged or distributed to any individual or organization outside of New Star Risk Retention Group and its underwriting department without your express permission, or as required by law.