Podiatrist Professional Liability Questionnaire

All Questionnaires submitted through this website are subject to carrier and underwriting review. By submitting a questionnaire through this website, there is no guarantee or warranty of coverage. Additional information may be required in order to provide a quote.

Don't want to submit an online form? Call our office at 866-467-3627 or Click Here to complete a pdf Questionnaire.

Practice or Employer Name *

Practice Address *

City, State, Zip *

Mailing Address (if different from Practice Address)

Are you seeking coverage for: *

 An Individual Podiatrist

 A Medical Group (Corporation and Providers)

 A Medical / Healthcare Facility or Service

 Ancillary Providers

 An Entity or Corporation Only

If an individual Podiatrist or practice manager, please provide your full name *

Primary Contact, if not the person above

Phone *

Email *

Your Website

Requested Effective Date *

Requested Limits of Liability * ----$200,000 / $600,000$1,000,000 / $3,000,000$2,000,000 / $4,000,000$3,000,000 / $6,000,000

How many hours per week do you practice? * ----Less than 20 hours per week21 hours or more per week

Is your practice comprised of *

 Non-surgical procedures only

 Surgical procedures

 A group of Podiatrists providing both

Are you performing procedures that require anesthetic or gaseous sedation, including post-op treatment? * ----YesNo

Do you currently have a Professional Liability policy in force? * ----YesNo

If Claims-Made, what is your current Retroactive Date?

Enter the State or States that you are requesting coverage *

Leave this field blank

Thank you! A representative will be in contact with you shortly. If you have any questions, please call our office at 480-348-2200

Processing...