Obtain a Quote Association Members

Obtain a Quote

Please complete the following fields. If you would prefer, you may email or fax copies of your current policy documents such as "declarations" pages or a schedule of benefits. [Click here for contact information]

(* denotes mandatory field)

Name:*   
Profession:
Email:*
Phone:*
Street Address:
City: * Zip:

Select the types of insurance you are seeking:*

  • :

You can submit now and be contacted regarding your selections OR you can complete the applicable sections below to receive a pricing idication electronically (requires a valid email address):

Professional Liability/Malpractice

Select your current or desired limits of liability:

Select your desired policy type:

Indicate your number of years in private practice/business:

Indicate your current retroactive or prior acts date (claims-made only):

On average, how many hours do you practice/work per week?:

Do you own a practice or business?

Disability

Occupation/specialty:

Gross Monthly Income (before tax): $

Gender:

Date of Birth: Year:

Benefit Duration Requested:

Waiting Period/Elimination Period:

Residual Disability Benefits?

Cost Of Living Adjustment?

Future Increase Option Amount Requested: $

Retirement Contribution Benefit? If so, enter current monthly contribution: $

Business/Practice Overhead Expense Disability Insurance

Occupation/specialty:

Gross Monthly Income (before tax): $

Gender:

Date of Birth: Year:

Benefit Duration Requested:

Waiting Period/Elimination Period:

Fixed Monthly Overhead Amount (excluding owner compensation): $

Life Insurance

Gender:

Date of Birth: Year:

Height: ft. in.

Weight: lbs.

Do you use tobacco?

Benefit Amount Desired: $

Term/Duration:

Business Owners Property/General Liability/Umbrella

Occupation/Industry:

Limits of liability:

Umbrella limit (optional):

Building Construction:

Within 5 miles of a Fire Station?

Within 1000 ft. of a Fire Hydrant?

Within 1000 ft. of a commercially navigable body of water?

Total Building Square Footage:

Square Footage of Your Office:

Replacement Cost Value of all Contents and Build-out of your office: $

Replacement Cost of Building (complete only if you own the entire building): $

Workers Compensation & Employers Liability

Occupation/Industry:

Total Estimated Annual Payroll: $

Total Compensation of Corporate Officers: $

Number of Employees: Full Time   Part Time

Long Term Care Insurance

Gender:

Date of Birth: Year:

Do you use tobacco?

Are you married?

*answer the following questions only if you are married and wish to obtain a pricing indication that includes a cost estimate of Long Term Care Insurance for your spouse as well

Spouse Date of Birth: Year:

Does your spouse use tobacco?

Individual Medical/Health Insurance

Home Zip Code:

Residence County:

Coverage Level:

Client Information:
    Coverage Level:
    Gender:
    Date of Birth: Year:

Type of Coverage (select all that apply):

Employee Benefits

Select all that apply:

Does your company currently offer insurance?

Current carrier and plan types offered:

Current renewal date: Year:

Types of health plans being considered: