Thank You - Answer Additional Questions | MEDPLI Professional Liability Insurance

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Address

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Things to know that will help us expedite your quote

Date you need the new coverage to go into effect

What is your NPI Number?

# of Claims reported in the last 10 years (copy)

# of providers in your practice

Average hours worked per week

Facilities where you have privileges

% of care delivered via telemedicine

Current Malpractice Insurance Carrier

Would you like to answer additional questions about your specialty to expedite your quote? If so, choose your specialty below. (If your specialty is not listed, additional questions are not yet available)

Sleeve Gastrectomy

Roux-en-Y (RNY)

Adjustable Gastric Banding (AGB)

Biliopancreatic Diversion (BPD) with duodenal switch

Intra-gastric balloon

VBLOC

Revisions (indicate type and # of procedures below)

Procedures performed under the IRB, including the SADI (Indicate type and # of procedures below)

Other

Indicate the extent of surgery you perform:

Assisting in major surgery on own patients:

Assisting in major surgery on patients other than your own:

Please check the procedures which you perform for which you are requesting coverage. Please check any procedure that you have performed in the last 5 years.

Abortion - 1st Trimester
Abortion - 2nd Trimester
Abortion - 3rd Trimester

Elective abortion % of practice

Therapeutic abortion % of practice

Please check the procedures which you perform for which you are requesting coverage. Please check any procedure that you have performed in the last 5 years.

Other Medical/Procedural Techniques not listed (please describe):

# of C-Sections performed per year

# of Vaginal Births performed per year

# of VBACs performed per year

Anterior Cervical Discectomy

Epilepsy Neurosurgery

Chiari Decompression

Craniotomy

Lumbar Puncture

Additional Neurosurgery procedures not listed (please describe):

Abdominoplasty

Breast Augmentation

Breast Reduction

Breast Explantation

Coronal Lift

Brazilian Butt Lift (BBL)

Endoscopic-assisted Forehead Lifts

Rhinoplasty (with or without septum)

Rhytidectomy

Suction-assisted Lipectomy

Ultrasonic-assisted Lipectomy

Large Volume Liposuction (5,000cc aspirate or more)

Reconstructive % of Practice:

Cosmetic % of Practice:

Orthopedics — hand surgery only

Orthopedics — fracture reduction - open

Orthopedics — fracture reduction - closed

Orthopedics — spine surgery with instrumentation

Orthopedics — spine surgery without instrumentation

Seeking coverage for: (Select) Individual or Group

Individual
Group

Please list any other brokers who are already working on your malpractice insurance:

Primary Practice Address:

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Preferred Mailing Address:

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Additional Information