Download the forms below as needed for your application and/or loss history requests. The application forms are in PDF format and viewable with the free Adobe Acrobat Reader. The loss history request letters are Word documents requiring Microsoft Word to open. Feel free to contact us with any questions.
Standard Market Applications
- Checklist
- Physicians and Surgeons Application (Form 07/05)
- Professional Organization Application (Form 07/05)
- Healthcare Provider Application (ex., Physical Therapist, Nurse, X-ray Tech) (Form 07/05)
- Supplemental Claims Form
- Supplemental Information form for VBAC
- Supplemental Information form for Radiologists
- Supplemental Information form for Surgicenters
Non-Standard or Excess and Surplus Lines
Use the following forms for when coverage cannot be obtained in the standard market.
Claims History Fax Requests
A ten year loss history is required from your prior insurance carrier(s). To obtain a loss history, sample fax request(s) can be copied and pasted to your letterhead and then faxed to your prior insurance carrier(s). To obtain the fax coversheet, click on the applicable prior insurance carrier(s) listed below. Use the blank fax form if your specific carrier is not listed and customize it as necessary.
- American Physicians / MICOA / Michigan Physicians
- Arthur J. Gallagher Co.
- Ascension Health
- Clarendon Western Indemnity Inc. Fronted by Gulf Atlantic Program
- Crittenton Hospital Medical Center
- Detroit Medical Center
- The Doctors Company
- Frontier Insurance Company
- Genesys Health System
- Henry Ford Health Systems
- Hudson / Transamerica Insurance Group (TIG)
- ISMIE Mutual
- Marsh / Lexington Insurance Company
- McLaren Regional Medical Center - Lapeer Regional Medical Center
- Medical Protective
- MHA Insurance Company
- Michigan Professional Insurance Exchange
- Michigan State University
- OHIC Insurance Company
- PIC-Wisconsin Inc.
- POH Medical Center
- POH Medical Center
- PPM Services Inc.
- ProAssurance / ProNational / PICOM
- ProAssurance Loss History Consent Release
- St. John Health
- St. Mary's Medical Center
- Star / Meadowbrook Insurance Group
- State Volunteer Mutual Insurance Company
- State Volunteer Mutual Insurance Company Release
- Synergy Medical / Saginaw Cooperative Hospitals
- University of Illinois - Chicago
- University of Michigan Risk Management
- Blank fax request