MQI Program Indication Form

Thank you for your interest in KLN Speciality Insurance. You can reach us via telephone860.920.7430, e.mailinfo@1mrm.com, or complete the Contact Form below.

After filling out the form, an KLN team member will reach out to you as soon as we can.

Practice Information

Practice Name
Contact Person
Office Telelphone
Office Fax
E.mail Address
Have you had a CCHIT Certified EMR system in place for more than one year? Yes
No

Physician Information

Physician Name
Specialty
Hours Worked per Week:
# of Office Locations
Board Certified? Yes
No
Coverage Type? Occurence
Claims Made
Current Liability Limits? $1m / $3m
$2m / $5m
Other
Current Carrier
Additional Information