CMIC MQI Program Information Form/Indication Form
Practice Information:
Practice Name:
Contact Person:
Office Address:
City:
State:
Zip Code:
Office Telephone:
Office Fax:
Email:
Key Information:
1.
Do you currently purchase your own Medical Profressional Liability Insurance?
Yes
No
2.
Are you:
Solo
Partnership
Group
(If so,how many?
)
Other:
Physician Information:
Physician Name:
# of years Claim-Free:
# of Claims in last 10 years:
Current Coverage Information:
Coverage Type:
Occurrence
Claims Made on:
Liability Limits:
$1m/$3m
$2m/$6m
Other:
Board Certified:
Yes
No
MA Medical
Society Member:
Yes
No
Hours Worked
Per Week:
CCHIT?
Surgery:
None
Minor
Major
# of office locations:
Current Carrier:
Current Broker:
Other Information:
KLN Specialty
Insurance, LLC
21 Oak Street
Suite 700
Hartford CT 06106
tel- 860.493.5700
fax- 860-547-1321
info@klninsurance.com
Home
-
Company Facts
-
Site Map
-
MRM
© 2003-2004 KLN Insurance, LLC