Medical/Professional Insurance Quotation

Please use this form to submit your current information to Keystone Consulting Group, so that we may give you a fast estimate on medical/professional liability coverage costs.



Contact Information

Name
Address
City State Zip Code
E-mail
Phone Fax


Physician Information

Name
Principle Office Address
City State Zip Code
E-mail
Phone Fax
Specialty
Choose: Surgery No Surgery Minor Surgery
License Number Current Board Certifications
Current Insurer
Expiration Date of Current Insurance
Retroactive Date of Current Insurance
Current Limits
If you selected "Other", please fill in the appropriate amounts here:


Claim History

Number of years without a claim
Year(s) and Amount(s) and brief detail of any claims


Please select from the following Medical Societies, IPA and other Medical Group Affiliations ALL THAT APPLY to qualify for additional discounts

Medical Group Management Association (MGMA) Yes No
Florida Chapter, American College of Surgeons (FCACS) Yes No
Florida Obstetric & Gynecology Society (FOGS) Yes No
Florida Society of Thoracic & Cardiovascular Surgeons (FSTCS) Yes No
Jacksonville Chapter American College of Surgeons (JCACS) Yes No
Neurological Injury Compensation Association (NICA) Yes No

Please select from the following hospital affiliations: (multiple selections are allowed - please hold down the Ctrl key while making your selections to choose more than one)

Do you currently carry Medicare/Medicaid Fraud and Abuse Defense Coverage? Yes No
Do you practice in a group? Yes No
If yes, please indicate number of physicians in the group
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
Additional comments or underwriting information