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Applicant Name			Principal Office
*Last:			P.C. Name:
*First:			* Address:
Middle:
Title:	Suffix:
Association Membership:      MSMS      MOA			* City:
			* State:	* Zip:
			*Phone:

Office Contact
Name:
Phone:
Fax:
Email:

Current Carrier:				Years in Practice:
Current Premium:				*Years Claims Free:
Have you ever had a malpractice claim? Yes    No
*Medical Speciality:				*County:		-- Select -- Alcona Alger Allegan Alpena Antrim Arenac Baraga Barry Bay Benzie Berrien Branch Calhoun Cass Charlevoix Cheboygan Chippewa Clare Clinton Crawford Delta Dickinson Eaton Emmet Genesee Gladwin Gogebic Grand Traverse Gratiot Hillsdale Houghton Huron Ingham Ionia Iosco Iron Isabella Jackson Kalamazoo Kalkaska Kent Keweenaw Lake Lapeer Leelanau Lenawee Livingston Luce Mackinac Macomb Manistee Marquette Mason Mecosta Menominee Midland Missaukee Monroe Montcalm Montmorency Muskegon Newaygo Oakland Oceana Ogemaw Ontonagon Osceola Oscoda Otsego Ottawa OUT OF STATE Presque Isle Roscommon Saginaw Sanilac Schoolcraft Shiawassee St. Clair St. Joseph Tuscola Van Buren Washtenaw Wayne Wexford
Coverage Type:		-- Select -- Occurrence Claims-Made TailGard		Physician Type:		-- Select -- MD DO CRNA PA Other
Effective Date:				Limits:		-- Select -- $100,000/400,000 $200,000/800,000 $300,000/1,200,000 $500,000/2,000,000 $1,000,000/4,000,000 $2,000,000/4,000,000
Expiration Date:				Work Status:		-- Select -- Full Time Part time Moonlighting Res First year Second year
Retroactive Date:				Deductible:		-- Select -- $0 $5,000 - Loss Only $10,000 - Loss Only $15,000 - Loss Only $25,000 - Loss Only $30,000 - Loss Only $50,000 - Loss Only $75,000 - Loss Only $100,000 - Loss Only $200,000 - Loss Only $5,000 - Loss Plus Expenses $10,000 - Loss Plus Expenses $15,000 - Loss Plus Expenses $25,000 - Loss Plus Expenses $30,000 - Loss Plus Expenses $50,000 - Loss Plus Expenses $75,000 - Loss Plus Expenses $100,000 - Loss Plus Expenses $200,000 - Loss Plus Expenses
Additional Notes (500 character limit.)