Podiatry Partner: Premier Podiatric Insurance Programs

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Medical Malpractice Insurance Quote

We would like to provide you with a free, no-obligation medical malpractice insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

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General Information
Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:

Current Policy Information

Carrier:

Expiration Date:

Retroactive Date:

Type:

Claims Made Occurrence

Limits:

$100,000/$300,000
$1 Million/$3 Million

$250,000/$750,000
Other: $

Annual Premium:

Practice Profile

Date Practice Started:

Are you practicing as a:

Owner Employee Independent Contractor

# of Podiatrists in your practice:

Employees:

Independent Contractors:

Type of Practice::

Solo Partnership Corporation

# of hours worked per week:

Are you Board Certified?:

Yes No

Professional Organizations
to which you belong:

ACFAOM
APMS

ACFS
ABPS

AAFS
Others:

Risk Management Practices
Risk management course completed within the past 1 year?:	Yes No
If Yes, Date Completed:
Use of written informed consent for surgical procedures?:	Yes No

Patient Profile
Percentage of your practice that involves the treatment of these patient types:
Athletes: % Children: % Diabetics: %
Other High Risk Patients:	%

Procedure Mix

Indicate the percentage of time spent annually in the following areas:
(total must equal 100%)

Non Surgical Care*: %

Soft Tissue Surgery: %

Osseous Surgery: %

* The following are considered "non-surgical": diagnostic and therapeutic injections; all nail related procedures; abscess incision and drainage; excision of molluscum contagiosum cysts and other benign legions (including warts and calluses); and treatment of ulcers.

Surgical Procedures Per Year

Estimated number of the following surgeries performed per year:

Joint or other Implants or Prosthesis
Ankle joint / lower leg surgery
Tendon Transfer Surgery
Achilles Tendon Surgery
Laser Surgery
Minimal incision foot surgery
Bunion Surgery
Non Osteotomy
Osteotomy

Loss and Disciplinary Action Information

Please give details below of all open/closed claims and disciplinary actions:

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

Medical Protective has 115 years of experience in protecting the assets and reputations of healthcare providers.

Phone: 800-771-1876 | Fax: 877-472-3007 | Email: medpro@podiatry-partner.com