CPP Quote

Professional Liability Coverage

Your Name

Mailing Address

Practice Addresses

Phone #  

Most convenient time to call  Morning (before 11:00 am) Afternoon (11:00 - 3:00) Evening (3:00 - ?)  

Is there a particular day that is most convenient to call?  No difference Monday Tuesday Wednesday Thursday Friday Saturday

DISCOUNTS

Your Graduation Date    Date you began practicing 

Have you attended a risk management seminar within the last year?  Yes No

Do you practice 16 hours a week or less?  Yes No

YOUR PRACTICE - Do you do the following?

Acupuncture  Yes No MUA  Yes No In a hospital setting?   MRI  Yes No Refer? Yes No

Draw Blood Yes No Refer? Yes No

INSURANCE BACKGROUND

Have you had any professional liability claims?  Yes No

Current Coverage Limits    Current Carrier 

Expiration Date    Policy Type  Occurence Claims-made   Prior Acts Date 

CPP Complete Practice Protection (if you are interested in professional liability only, you need not complete this section)

PRACTICE INCOME INTERRUPTION

Among the many things the plan does, its valued practice income protection pays you the daily income you select, for the # of days you select, with no requirement that you document your losses or that you reschedule patients.

$200 a day is the minimum.  How much money would your need to receive for each day that you cannot practice?  $

32 and 1/2 days is the minimum time.  How many days would you need coverage for?  

BLANKET PRACTICE PROPERTY PROTECTION

Imagine that tomorrow you had to replace everything:  operations, tools, office equipment, x-rays, patient charts, records, furniture, decor the personal property in the office, your accounts receivable the became un-collectable.

How much money would you need?  $

When does your current coverage expire?   

What is your building construction?  Block Frame Concrete Steel

Building Coverage

If you own a building, you can insure it too under the plan

Would you like to see what it would cost to insure your building under the plan?  Yes No

Building value  $

Workers' Compensation

Please provide a quote for Workers' Compensation Yes No   Annual Payroll $