SCW Agency

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Professional Liability
professional liability insurance For more than 30 years, SCW Agency Group has provided physicians with outstanding professional liability coverage and unparalleled customer service. Using our extensive knowledge of liability issues and our relationships with the best insurance underwriters, we have the flexibility to provide you with a coverage plan that is right for you.

We only work with insurance companies that are rated among the highest with A.M. Best and Standard & Poor's, so you are always guaranteed to receive the best insurance products for your money.

PROFESSIONAL LIABILITY QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only.

Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Personal Information
First Name  
Last Name  
Date of Birth  
E-mail address  
Phone Number  
Office contact  
Fax Number  
Address  
City  
State  
Zip code  
How would you prefer to be contacted  
regarding your quote?  		 Phone Fax Mail   E-mail
If you would prefer to be contacted by phone,  
please let us know the best time to call.  

Practice Information
Select Client Type  
Corporate Name  
Number of Doctors in Practice  
Urgent Care  
If yes, annual PPV  
Shared Limits  
Is Practice in more than one location  
Location 1  
Location 2  
Location 3  
Years in Practice  
Specialty  
Invasive Procedures  
Sub-specialty  
Classification  
Board Certified  
Certified by  
License   MD
DO
DDS
MD Resident
NP
PA
Other
Member of MSMS or MOA  
Number of Hours  
Current Carrier  
Amount of Premium  
Employment  
Occurence   Limits
TailGard   Limits
Claims Made   Limits
Effective Date  
Retro Date  
Claims, including pending claims or NOI's  
in the past 10 years  
If yes, date(s) and amount(s) paid  
Hospital Privileges  
Ancillary Staff (is NP/PA)  
Completed a Risk Management Program  
in the past 12 months  
Other Lines Needed  
(WC, BOP, Auto, Home, etc.)  

Questions and Comments