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Professional Liability Quote
Professional Liability Insurance Quote

Contact Information
Full Name:
Street Address:
Primary Practice Address
City, State & Zip: City, State & Zip:
E-Mail Address:
Best Time To Reach You:
Day Telephone:
Eve Telephone:
Fax:
Date of Birth License #:
Practice Information
Check each that applies to your practice:
Individual Partnership Association Group Practice
Professional Affiliation Other
Current Professional Liability Coverage
Current Insurance Carrier:
Limits of liability: $ per claim $ aggregate
Effective Date: Premium: $ Retroactive Date:
Professional Information
Occupation: Practice Operates: Board Certified
Specialty: Full Time
Part Time
Yes
No
Claims History
Claim #1 Claim Status: Closed Open
Claimant Name:
Date of occurrence:
InsuranceCarrier:
Locationofoccurrence:
Allegations:
Amount paid on your behalf: $
Amount reserved: $
Claim #2 Claim Status: Closed Open
Claimant Name:
Date of occurrence:
InsuranceCarrier:
Locationofoccurrence:
Allegations:
Amount paid on your behalf: $
Amount reserved: $
Claim #3 Claim Status: Closed Open
Claimant Name:
Date of occurrence:
InsuranceCarrier:
Locationofoccurrence:
Allegations:
Amount paid on your behalf: $
Amount reserved: $
Additional Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

    Kupiec Insurance Group
    15 Brintons Bridge Road, Suite 100
    West Chester, PA 19382

    Office: (610) 526-1853
    Fax: (484) 631-1320
     

    © Kupiec Insurance Group, 2012


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