ONLINE QUOTE FORM FOR PHYSICIANS AND SURGEONS
PROFESSIONAL LIABILITY INSURANCE

Please answer the questions below by providing as much detail as possible. All information gathered on this form will remain confidential. Before you can submit a Request for Quote, please review our Privacy Policy and HIPAA form, then check this box after you have read, accept and understand them.


Submitted by:

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Agency:

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Mailing Address:

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City:

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State:

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Zipcode:

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Phone Number / Area Code:

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Fax:

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Email Address:

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Applicant`s Instructions:
1. Complete the online form including the claim form if applicable
2. If you have a CV.(resume) please email to pbs@pbsinsurance or fax to 502-254-1056
3. Please DO NOT complete the application earlier than 60 days before the proposed effective date of coverage.

     
 

General Information:

  
1.
 Full Name:  
2.
 Professional Designation: Other:
3.
 Principal Practice Address:
4.
City: State: Zip: County:
5.
Phone: Fax:
6.
 Email: Website:  
7.
 Date of Birth (MM/DD/YYYY) / / Soc # (xxx-xx-xxxx) - -
A.
 Place of Birth
8.
 Federal Tax ID Number Federal DEA License Number
9.
 Effective Date of Policy Desired (MM/DD/YYYY) / /
10.
 If claims made date (MM/DD/YYYY) / /
11.
 Retroactive date (MM/DD/YYYY) / /
12.
 Desired Limits: Fully Insured Other Limits:
  Defense Only (Reimbursement)  
13.
 Are you a U.S. Citizen? yes no  
  If NO, what is your status?
14.
 Type of Practice
Other: or Employee of: or Contractor of:
A.
 Do you want coverage for the entity named above: (Enter Name of Entity)
15.
 States in which you Practice  
  State: Active:
  State: Active:
  State: Active:
16.
 Please provide the name(s) for all Hospitals and Surgi-Centers where you are currently staffed:
  Name: City: State: % of work:
  Name: City: State: % of work:
  Name: City: State: % of work:
17.
 Avg. # of hrs. per week worked (Includes hospital & office hours for which coverage is sought)
18.
 Are you currently a hospital cheif of staff or head of any hospital department or medical director? yes no
If yes, Explain?:
   
 

Education and Training:
1.
 Specialty Other:
2.
 Sub-Specialty
3.
 Board Certified yes no  
A.
 If yes, which specialty:
B.
 If no, why not?:
4.
 Please provide the following:  
    Name of Institution:    
  Medical School: State
  / /    
  Internship: State
 
Date Completed:
 
  Residency (Specialty): State
 
Date Completed:
/ /  
  Fellowship (Specialty): State
 
Date Completed:
 
5.
 If you Graduated from a Foreign Medical School, are you certified by the Educational Council for Medical School Graduates? yes no
B.
 If yes, Provide the following: Year of Certification:
Describe Medical Degree: (Ex: MD)