Save 15% or more

If we can save you 15% or more on your malpractice premium we will respond in less than 24 hours with a premium indication and assist you with the next steps in joining this exclusive club.

Premium Indication Form

So let's start saving some money.

It will be helpful if you have your current policy with you when you fill out this form.

We need some information to develop a preliminary premium indication. This is not a binding quote or offer of insurance. That will occur after you submit a formal application. In virtually all cases our premium indication is the same as or higher than our final offer of insurance coverage.

Your Full Name: *
Medical License #: *
Company Name, If Applicable: *

Indicate your preference for how we should contact you:	Please contact me by email Please contact me on my cellular phone Please contact me on my direct office number
E-Mail Address:
Cellular Phone:
Direct Office Phone:

What is the status of your Board Certification?:	I am Board Certified I am Board Eligible I am Not Board Certified or Board Eligible

Please indicate National Associations in which you are a current member:	American College of Radiation Oncology American Society of Clinical Oncology American Society for Therapeutic Radiology & Oncology American Urological Association Society of Surgical Oncology
Other National Society:

Effective date of your CURRENT policy: *
Retroactive date of your Current policy: (applies to claims-made policies)

Select your PER CLAIM Limits of Liability:	$100,000 $250,000 $500,000 $1,000,000 $1,300,000 (New York Only) $2,000,000 $3,000,000

What is your current premium? (Please do NOT include any State-specific patient compensation fund assessments):

Select your medical specialty:	Medical Oncology or Hematology Radiation Oncology Surgical Oncology Urology

State where your primary practice is located:
In what county(ies) do you practice? If more than one, give us a rough idea of the percentage of your practice in each county:
Approximately how many hours do you work per week, on average:	32 or more hours per week Less than 32 hours per week
Enter the APPROXIMATE date that you FIRST started in medical practice:

Have you experienced ANY malpractice claims or been subject to a review by any State Licensing Authority or other regulatory agency in the past 10 years?:	Yes No

Please provide any comments that will clarify your responses, or assist us with providing the most accurate premium indication::

National Medical Professional Risk Retention Group, Inc.
PO Box 50933 Fort Myers, FL 33994
888.804.9556

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