PODIATRY
MALPRACTICE
PREMIUM INDICATOR		  We would like to provide you with a free, no-obligation    podiatry malpractice 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:   County:   State:   Zip: 
Office Phone:   Office Fax:
Date of Birth:   Date Practice Started:

 

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

 

Practice Information

Check/Complete each that applies to your practice
 I have completed a risk management course in the past two years:  Yes  No

 I teach:  Yes  No       I am enrolled in a residency Program:  Yes  No

 I am Board Certified:  Yes  No

 I practice:  Full Time  Part Time     Practice Hours/Week: 

 I have had additional medical training after my residency:  Yes  No

 I am employed 100% by another Podiatrist:  Yes  No

 Greater than 25% of my practice involves treating diabetic patients:  Yes  No

 I use written Informed Consent for surgical procedures:   Yes  No

 Patient medical history is updated each visit:  Yes  No

 I perform the following procedures (percentages):

 Non Surgical Care:  %     Soft Tissue Surgery:  %     Osseous Surgery: %   

 

Surgery Information
 The Estimated Number of the Following Procedures I Perform Per Year:

 Implants/Prosthesis:         Ankle/Joint/Lower Leg Surgery:

 Tendon/Tendon Transfer Surgery:       Involving Sports Injuries to Children:

 

 

Claims History
This information is kept strictly confidential

Claim #1   Claim Status: Closed   Open
Patient 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
Patient 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
Patient 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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