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Quick Premium Indication

Complete This Form to Get a Quick Premium Indication for Podiatrist Professional Liability Insurance

Name:  
Primary Office Address:  
City:  
County:  
State:      Zip: 
Phone:  
Fax:  
E-mail:  
Date of Birth :   / /
Date Practice Started:   / /

CURRENT INSURANCE INFORMATION

Insurance Company Name:  
Current Policy Expiration Date:   / /
Annual Premium Paid Last Year:   $
Current Policy Limites and Deductibles  
Retro Active Date:   / /
Practice Hours per Week  

ABOUT YOUR BUSINESS

I have completed a risk management course in the past 2 years.
   Yes No
I teach.
  Yes No
I am enrolled in a residency program.
  Yes No
I am board certified.
  Yes No
I have had additional medical training after my residency.
  Yes No
I am a member of a regional or national podiatric organization
  Yes No
I practice as:
   
Owner     Employee of another DPM      Associate     Independent Contractor
My practice is:
   
Solo Practice      Partnership     Corporation     LLC     Associateship     Multi-Podiatrist
I employ other DPMs in my practice.
  Yes No
If yes, how many are employees?
 
How many are Independent Contractors?
 
I use Written Informed Consent for surgical procedures.
  Yes No
Patient medical history is updated each visit.
  Yes No
The percentage of my patients who are diabetic is:
   
0-15%     16-30%     31-50%     51-70%     71-100% 
 
The time I spend performing the following procedure is:
Non Surgical Care %
Soft Tissue Surgery %
Osseous Surgery %
Must equal 100%
 
The estimated number of the following surgeries I performed per year is?
Implants/Prosthesis
Ankle / joint / lower leg surgery
Tendon / Tendon Transfer Surgery
Bunion Surgery  
  Non Osteotomy
  Osteotomy
Sport Injuries or Children (Surgery Only)
Loss Information - Tell us about any claims made against you:
No Known Claim History
Claim Report Date Details Dollar Amt.
/ /
/ /
/ /
/ /

    

 
5628 East Thomas ~ Phoenix, Arizona 85018 ~ 480-990-1900 ~ FAX: 480-481-9551
joeb@generalsouthwest.com ~ US Postal Address: P. O. Box 189 Scottsdale, Arizona 85252