United Assurance, Inc.

 
PROFESSIONAL
LIABILITY
PREMIUM INDICATOR		   We would like to provide you with a free,no-obligationprofessional liability premium indicator. Please provide as much information possible for the most accurate premium. This information will be kept confidential and will be used for this purpose only.
 

General Information
Your Name:
Your E-Mail Address:
Primary Practice Address:
City:   County:   State:   Zip: 
Office Phone:   Office Fax:
Date of Birth:   License Number:


Practice Information
Check each that applies to your practice
Individual
Group Practice		 Partnership
Professional Corporation		 Association
Affiliation		 Other: 


Current Professional Liability Coverage
Current Insurance Carrier:
Limits of liability: $ per claim       $ aggregate
Effective Date:   Premium: $   Retroactive Date:


Professional Information
Occupation:
Practice Operates:
Board Certified
Specialty:
Full Time
Part Time
Yes
No


Claims History
This information is kept strictly confidential

Claim #1
   Claim Status: Closed   Open
Claimant Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #2
   Claim Status: Closed   Open
Claimant Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #3
   Claim Status: Closed   Open
Claimant Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Amount paid on your behalf: $   Amount reserved on behalf: $


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


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