Quick Quote | The Keane Insurance Group

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All information disclosed on this form is 100% confidential and will only be used for the purpose of obtaining a quotation. Please complete all questions below, being as specific as possible. Quotations will be gathered from all major companies offering medical professional liability insurance. This Quick Quote Form does not constitute a formal application for insurance. Any premium indication based on this request is not binding.

**NOTE** Please specify if you are a member of one of our endorsed programs through a specific medical association in order to differentiate your quote request.

Physician Name:

Association:

Group Name:

Contact Person:

Email Address:

Address Line 1:

Address Line 2:

City:

State:

Zip:

Phone Number:

Fax Number:

Specialty:

Perform Invasive Surgery?

If Yes, Liability Limits:

Are You an Owner at a Surgery Center?

Current Carrier:

Expiration Date:

Retroactive Date:

Claims Made:

Occurrence:

Expiring Premium $

Do You Practice:

Full Time
Part Time

Corporate Coverage:

Claims History

Have You Ever Had a Claim Filed Against You?

If so, #

For each claim, please provide 1. the date of loss, 2. date the claim was filed, 3. the status of the claim, and 4. the amount of settlement:

Comments - Feel Free to List Additional Physicians / Specialities in Your Group:

How Did You Hear About Us?

You May Contact Me Via Email in the Future:

Yes
No

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