Professional Risk Planners, Inc. - Insurance and Bonding Specialists Professional Risk Planners, Inc. - Insurance and Bonding Specialists Professional Risk Planners, Inc. - Insurance and Bonding Specialists
(631) 360-8800 Phone
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Protecting Your Business,
Your Lifestyle, and Your Employees

Professional Risk Planners, Inc. - Insurance and Bonding Specialists
Professional Risk Planners, Inc. - Insurance and Bonding Specialists
Professional Risk Planners, Inc. - Insurance and Bonding Specialists
Professional Risk Planners, Inc. - Insurance and Bonding Specialists
Professional Risk Planners, Inc. - Insurance and Bonding Specialists
Professional Risk Planners, Inc. - Insurance and Bonding Specialists
Professional Risk Planners, Inc. - Insurance and Bonding Specialists
Professional Risk Planners, Inc. - Insurance and Bonding Specialists

Physician

Insurance Quote

We would like to provide you with a free, no-obligation physician insurance 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: 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:     Retroactive Date:
Premium: $

 

Physician / Physician Assistant Information
Specialty:
Practice Operates:
Board Certified
Full Time   Part Time
Yes   No

 

Claims History
This information is kept strictly confidential

Claim #1
  Claim Status: Closed   Open
Patient Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Dollar Amount: Paid on your behalf: $   Reserved on your behalf: $

Claim #2
  Claim Status: Closed   Open
Patient Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Dollar Amount: Paid on your behalf: $   Reserved on your behalf: $

Claim #3
  Claim Status: Closed   Open
Patient Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Dollar Amount: Paid on your behalf: $   Reserved on your 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.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   


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Professional Risk Planners, Inc. - Insurance and Bonding Specialists
Professional Risk Planners, Inc.
670 Old Willets Path, Suite A
Hauppauge, New York 11788
Phone: 
Fax: 
(631)360-8800
(631)360-8875
ins@proriskplan.com

Professional Risk Planners, Inc. - Insurance and Bonding Specialists
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Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.

Professional Risk Planners, Inc. - Insurance and Bonding Specialists
Professional Risk Planners, Inc. - Insurance and Bonding Specialists

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Privacy Notice: Your privacy while visiting our website is important to us. Because there are parts of our site where we ask you to provide us with certain types of personal information about yourself, we want you to know how we will use it. We will use the information that you give us explicitly for the purposes stated on any online electronic form on this website, which in most cases will be for quoting, service, and information requests. We will not sell, share, or turn over any information you provide to any other person or organization. We may make it part of a reference source for future contact with you by our organization. We take your privacy very seriously, and ask that you contact us directly if you have any questions or concerns about the use of our website.