Medical Malpractice Insurance Intake Form
A streamlined way to provide your information and receive customized insurance quotes
MedQuote is a digital intake form that helps healthcare organizations quickly provide the information needed to receive medical malpractice insurance quotes.
Complete this form at your own pace, download it as a PDF, and email it to your assigned agent. Your agent will then review your information and prepare customized insurance quotes tailored to your organization's specific needs.
How it works:
No commitment required. Completing this form simply helps us prepare accurate quotes for your review.
You may skip any question. Complete only what's relevant to your organization.
Your answers are automatically saved every 2 seconds. Return anytime to complete.
Download your completed form as a PDF anytime and email it to your agent for quote preparation.
The form is organized into 13 sections covering different aspects of your organization
Organization details, ownership, and contact information
Requested policy terms and current insurance
Bed counts, patient volumes, and services
Staff credentials and screening processes
Obstetrics, surgery, and anesthesia details
Department operations and quality measures
Facilities and vehicle exposure information
Accreditations and organizational policies
Past claims and known incidents
State fraud warning acknowledgements
Professional history and disclosures
Procedures performed in your practice
Final review and form completion
Estimated time: 30-60 minutes (can be completed over multiple sessions)
Once you've filled out the form, you can download it as a PDF at any time. Email the completed PDF to your assigned agent, who will review your information and prepare customized insurance quotes for your organization.
If you need assistance completing this form, please contact your assigned insurance agent directly.
Your Licensed Insurance Agent
Important: You may skip any question. All fields are optional.
This intake form is for preliminary quote purposes only. Completion of this form does not bind coverage or constitute acceptance of insurance.