Burnette Insurance Agency, Inc. -- Medical Malpractice Premium Indicator


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.

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.

Please click on the "Submit Form" button to send your request.
One of our representatives will respond to your submission as soon as possible.

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

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: $