Medical Malpractice Insurance Agent: Cunningham Group. Free Med-Mal Insurance Quotes.

Cunningham Group - Key Insurance Products - Medical Malpractice Insurance

Click here to be like the thousands of physicians who have received free quotes from Cunningham Group.
It's quick and simple, and could save you money on your malpractice insurance coverage.
For even faster service, call 800-962-1224

Did you receive our Best Rate Survey and want to learn more?
Click here to Request a Free, No Obligation Quote.
We offer low rates and excellent service.

Cunningham Group Medical Malpractice Insurance- Key Insurance Products - Protecting Your Practice, Managing Your Risk


	Overview


	Physicians Medical Professional Liability › Medical Malpractice Indication Form Medikey^sm Billing Errors & Omissions Insurance › Medikey^sm Indication Form Business Owners Policy › Indication Form Workers' Compensation and Employer's Liability › Workers' Compensation Form Employee Benefits › Employee Census Form

All fields are required unless marked optional.

First Name:

Middle Name (opt.):

Last Name:

Title

Date of Birth:

Practice Name:

Address Line 1:

Address Line 2 (opt.):

City:

State:

Zip Code:

County:

Number of Physicians in Your Practice:

Specialty:

Date You Began Practice:

Has your license to practice medicine, permit to prescribe drugs, specialty board certification or membership in any professional society been revoked, denied or limited?

Yes No

Has any hospital restricted or revoked your privileges or invoked probation for any cause?

Yes No

Have you been treated for alcoholism, narcotics addiction or mental illness?

Yes No

Have you been the subject of any claims or suits (if yes, provide # below)?

Yes No

Has your professional liability insurance ever been cancelled, non-renewed or surcharged?

Yes No

Please provide details for any questions answered "Yes" above:

Are you board certified?

Yes No

Are you board eligible?

Yes No

Hours per Week You Work:

Do You Perform:

Minor Surgery Major Surgery

Assist in Surgery

If Family / General Practice:

Number of Vaginal Deliveries:

Number of C-Sections:

If Orthopedic Surgery:

Spinal Surgery

If Otolaryngology:

Cosmetic Plastic Surgery

If Internal Medicine / Cardiology:

Angiography, Angioplasty, Cardiac Catheterization

If an OB/Gyn:

Deliveries you Perform per Year:

Name of Current Carrier:

Expiration Date

Type of Coverage:

Claims-Made Occurence

If Claims-Made, Provide Retroactive Date:

Limits of Liability:

Premium:

Office Contact Person:

Phone Number:

Fax (opt.):

Email Address:

Please Contact at a Later Date:

Return to top of page