Medical Malpractice Insurance - Professional Liability Insurance for Physicians, Doctors, Dentists and Chiropractors

Baxter & Associates, LLC
1 South A Street, Suite 102
Pensacola, FL 32502

TEL 800.641.8865
FAX 888.287.8894

To request a quote, you may either complete our online fillable PDF application
and return it to us by email, or you may complete the online form provided below.

Please feel free to contact us for any assistance by calling: 800-641-8865
Thank you!

Medical Doctor / Doctor of Osteopathy
Professional Liability Request for Quote Inquiry

Name:
Contact Person:
Phone Number:		Fax Number:
Email Address:
Street Address:
City:		State: Zip:
Your Medical Specialty:
Do you perform surgery?
Are you board certified?		Yes No
Number of years in practice:
Number hours practice/week:
Have you had malpractice claims?		Yes No
If yes, list each:
COVERAGE NEEDS:
Proposed Effective Date:
Proposed Retroactive Date:
Proposed Liability Limits:		Specify:
Comments:
Please share how you learned about us? You may choose all that apply:		Google Yahoo MSN/Bing Dogpile Mailing Referral Convention/Trade Show If Other, please specify: Other