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

Baxter & Associates, LLC
4400 Bayou Blvd, Suite 52-B
Pensacola, FL 32503

TEL 800.641.8865
FAX 888.287.8894

Chiropractic Professional Liability Insurance
Request for Quote Inquiry

Name:
Contact Person:
Phone Number:		Fax Number:
Email Address:
Street Address:
City:		State: Zip:
Which describes your practice?
Number of years in practice:
Number hours practice/week:
Have you had malpractice claims?		Yes No
If yes, list each:
COVERAGE NEEDS:
Type of Coverage:		Claims-made Occurence Both
Proposed Effective Date:
Proposed Retroactive Date*:		*claims-made only
Proposed Liability Limits:		Specify:
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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