Premium Indication Request Form

Neff & Associates has exclusively represented physicians for their professional liability insurance for over 30 years. We are confident you will be impressed with the cost and coverage comparison we can provide. References are available upon request.

To compare to your current coverage, please submit the following online form, or print and fax it to (410) 289-7887. You are also welcome to call Neff & Associates at (800) 358-7381.

Premium Indication Request Form

Contact Information

Contact Name

Phone

Practice Type

Solo (one physician)

Group (2 or more physicians)

Group

Solo

Practice Name

Physician Name

City

State

Specialty

Retroactive Date

# of Physicians (Maximum 10)

# of Ancillaries (PAs, NPs, etc.)

Average Number of Hours per Week

10 hours per week or less

11 - 20 hours per week

21 or more hours per week

Current Carrier

Limits of Liability

Policy Expiration Date

Current Premium