Get Service > Medical Malpractice – Quick Quote Form
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		Crosby & Henry can provide a non-binding quick-quote for medical malpractice insurance. Fill out the form below, click Submit, and Crosby & Henry will work to process your request during regular business hours. Please telephone us with any questions.

Your Name:		Email (required):
Mailing Address:		Telephone Number:
City:		Fax Number:
State/Zip:		Are you a member of?
Practice Location Addresses, if different:		KCMS KCOA	Yes   No Yes   No If so, you may be eligible for member advantages.
Date of Birth:		# Years In Practice:
Degree:		Specialty:
Board Certified:	Yes No	Sub-Specialty:
Type of Surgery:	Major Surgery Minor Surgery No Surgery
Practice Hours:	Full Time Part Time 16-30 Hours Per Week Part Time 1-15 Hours Per Week
	COVERAGE OPTIONS:
Proposed Effective Date:		Requested Limits of Liability:
Claims-Made Coverage:	Yes No	Claims-Made Retroactive Date:
Occurence:	Yes No	Prior Acts Coverage:	Yes No
Corporation Coverage:	Yes No	Solo Corporation:	Yes No
Name of Corporation:
Number of Physicians Associated with Named Corporation: (A separate request will need to be completed for each physician requesting coverage)
Ancillary Staff:
Quote Building and Contents, Equipment?	Yes No	Renewal Date of Current Policy:
Quote Worker's Compensation?	Yes No	Renewal Date of Current Policy:
	CORPORATION CLAIMS EXPERIENCE Ten year history, including Notices of Intent, updated within the last 90 days. For Ohio, include 180 day letters.
Incident Date:	Report Date:	Closed Date:	Amount Paid:
	CURRENT MALPRACTICE INSURANCE Ten year history, including Notices of Intent, updated within the last 90 days. For Ohio, include 180 day letters.
Company:		Limits of Liability:
Policy Term:	From: To:	Current Premium:
Best Time to Call You:
This information will be used for premium indication purposes only. Coverage will not be bound until a complete application and request for coverage is received and accepted. Thank you in advance for your consideration of Crosby & Henry.