| Name: |
|
| Address: |
|
| City |
|
| County |
|
|
State
|
Zip
Code |
| Office
Phone |
|
| Fax
Number |
|
| E-mail
Address |
|
| ICA
Member? |
YES
NO |
| Are
you a: |
Doctor
Student |
| Graduation
Date |
|
| School |
|
| Are
you currently insured for malpractice? YES
NO |
Who
is your
insurance Carrier? |
|
What
are the
limits of liability? |
|
|
| Renewal
Date |
|
| Is
your policy a (an) |
Occurrence
Claims
Made |
| How
many years? |
|
| Annual
Premium: |
|
| Reason
for choosing your current malpractice carrier |
|
| Would
you be interested in more information on other insurance
coverages through the ICA's ChiroSecure Program? Yes
No |
| Contact
person |
|
| Best
time/day to call |
|