Medical Malpractice Insurance Services
provided by
United Agencies, Inc. - United Western Division
Insurance Agents & Brokers
License #OD73849

Information Form

Please complete the appropriate fields in the form below. (Fields with an asterisk [*] must be completed for the quote to be processed.) After verifying the accuracy of the information, click on the SUBMIT button.

Please complete this form only if your practice is
located in California

Thank you.

 Please e-mail a cost quote to me.  Please mail an application packet to me.  Please call me. Download an application form now.

Applicant Information:

Your name*  
Your e-mail address*  
Street address  
City  
State       Zip Code
Phone number*  
Fax number  

How long at this location?  

Practice Information:

Check each of the following that applies to your practice:

    Individual
    Group Practice
    Partnership
    Professional Corporation
    Association
    Affiliation
    Other:

Number of
physicians in group   2-4     5-8     9+

If in a group practice, is the group owned, managed or controlled by any other healthcare entity?    Yes     No
If "yes", name the entity and the relationship:

Current Professional Liability Insurance Coverage:

Current insurance carrier  
Limits of Liability: $ - $
Deductible: $
Renewal Date: //
Premium: $
Per Quarter: $ or Annually: $
Retroactive Date: //

Requested Coverage

My desired effective date for
Medical Malpractice insurance is   //

Desired limits
(Check all you want quotes for)

    $1,000,000 - $3,000,000
    $2,000,000 - $4,000,000
    $5,000,000
    Other $ - $

Number of employed
Phsician Assistants/Nurse Practitioners

Physician/Surgeon Information:

Specialty:
Full Time         Part Time
Years Experience in Specialty:
Years Practicing in Community:
Board Certified? Yes         No
Any previous claims activity? Yes         No
If yes, Doctor Name:
Date of Claim: //
Patient Name:
Status:
    Open
    Closed Claim
    Settlement
    Judgement
    Dismissal

If Open, Reserve Amount: $
If Closed, Amount Paid: $
               Defense Costs: $