Contact Information

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Name*

Phone*

Secondary Phone

Fax

Email*

Practice Information

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Is your Chiropractic License Active? Yes No

Practice Address*

City*

State*

Zip*

Are you:* Full Time
Part Time (20 hours or less)

How many patients do you see per week?

Has a malpractice claim or a board dispute ever been filed against you or your associates? Yes No

Insurance Information

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Current Malpractice Carrier

OR

No Insurance

Renewal Date ...

Current Premium

Type of policy interested in Claims Made Occurrence

Policy Limits Select One $100K/$300K $200K/$600K $500K/$1.5M $1M/$3M $2M/$4M

Retroactive Date (if claims-made policy) ...

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