Golden Empire Insurance Agency
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Golden Empire
   Golden Empire Insurance Agency
"Old World Values With New World Technology"
  Medical Mal-practice Insurance Quote

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.

   

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This Medical Malpractice Premium Indicator Form Copyright © 1998-2003 by ENHANCED Web Services

Golden Empire Insurance

Golden Empire Insurance Agency

28720 Roadside Drive, #376
Agoura Hills, CA 91301
Phone: (800) 899-5556   /   (818) 597-7880   Fax: (818) 597-0078
Email: info@goldenempireins.com

CA License #: 0338632

Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.

 
© Copyright 1999-2003 Golden Empire Insurance Agency

 
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