Professional Liability Premium Indicator

We would like to provide you with a free, no-obligation professional liability premium indicator. Please provide as much information possible for the most accurate premium. This information will be kept confidential and will be used for this purpose only.

General Information
Your Name:
Your E-Mail Address:
Primary Practice Address:
City:	State: Zip:
Office Phone:	Office Fax:
Date of Birth:	License Number:

Practice Information

Check each that applies to your practice

Individual
Group Practice

Partnership
Professional Corporation

Association
Affiliation

Other:

Current Professional Liability Coverage
Current Insurance Carrier:
Limits of liability:	$ per claim $ aggregate
Effective Date:	Premium: $
Retroactive Date:

Professional Information
Occupation:	Specialty:	Practice Operates:	Board Certified
		Full Time Part Time	Yes No

Claims History
This information is kept strictly confidential

Claim #1	Claim Status: Closed Open
Claimant Name:	Date of occurrence:
Insurance Carrier:	Location of occurrence:
Allegations:
Amount paid on your behalf:	$ Amount reserved on behalf: $

Claim #2	Claim Status: Closed Open
Claimant Name:	Date of occurrence:
Insurance Carrier:	Location of occurrence:
Allegations:
Amount paid on your behalf:	$ Amount reserved on behalf: $

Claim #3	Claim Status: Closed Open
Claimant Name:	Date of occurrence:
Insurance Carrier:	Location of occurrence:
Allegations:
Amount paid on your behalf:	$ Amount reserved on behalf: $

Additional Comments

Please give any additional comments you feel appropriate for this premium indicator. If you have
additional information where there was not enough space, please enter them here.

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One of our representatives will respond to your submission as soon as possible.

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Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.

Community Insurance Group

139 Harristown Road, Suite 202
Glen Rock, New Jersey 07452

Phone:
Toll Free:
Fax:
Fax (NJ only):

201-444-4426
855-344-4426
201-444-0731
800-440-2267