Parsons & Associates, Inc. -- Professional Protector Plan®

Parsons & Associates. Inc. -- Insurance & Risk Management

The painless estimate: Professional Protector Plan®
By answering these few questions, we can offer you a reliable
estimate of what coverage under the plan would cost. If you
decide to buy coverage, we'll need a complete application.

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We only accept inquiries for insurance written in New York State

Professional Liability Coverage

For the most accurate proposal please provide copies of insurance policy cover pages

Name:

Mailing Address:

City: State:    ZIP:

Practice Address:

City: State:    ZIP:

Phone: ( ) -    Fax: ( ) -

Best time to call: am pm

Email:

Discounts

Your Graduation Date:

Have you attended a loss-control seminar within the last year?: Yes No

Do you practice 16 hours a week or less?: Yes No

Your Practice

Do you treat patients under: Conscious Sedation Deep Sedation or General Anesthesia

Only in a hospital?: Yes No

Are you an oral surgeon?: Yes No

Insurance Background

Have you had any professional liability claims?: Yes No Current Carrier:

Current Coverage Limits: $ Expiration Date:

Occurrence Claims-made Prior acts date:

Professional Protector Plan® Complete Practice Protection

Practice Income Interruption

Among the many things the plan does, its valued practice income protection pays you the daily income you select, for the number of days you select, with no requirement that you document your losses or that you reschedule patients.
Two hundred dollars a day is the minimum. How much money would you need to receive for each day you can't practice?
$
Thirty-two and a half days is the minimum time. How many days would you need coverage for?

Blanket Practice Property Protection

Imagine that tomorrow you had to replace everything: operations, tools, office equipment, x-rays, patient charts, records, furniture, decor, the personal property in the office; your accounts receivable that became uncollectible.
How much money would you need?
$
When does your current coverage expire?

Practice Contents and/or Building Coverage

What is your building's construction type?
Do you own or rent? Own Rent
If you own, building value: $

NYS Disability Benefits / Workers Compensation

# Employees: Male Female Payroll: $

Additional Comments:

Please give any additional comments about the coverage you desire:

The Professional Protector Plan® is a registered trademark of Poe & Brown Insurance, Inc., Tampa, Fl., and is underwritten by the following CNA Insurance companies: Continental Casualty Company, National Fire Insurance Company of Hartford and American Casualty Company of Reading, Pennsylvania. CNA is a registered service mark of CNA Financial Corporation.

Thank you for your time in submitting this proposal form. One of our representatives will respond to your submission as soon as possible!