MALPRACTICE INSURANCE QUESTIONNAIRE

 

Qualified members of the American Academy of General Physicians (AAGP), who are in good-standing, and who are in compliance with all resolutions, codes, policies and opinions of the AAGP, may obtain medical malpractice insurance, at discounted premium rates or premium rates lower than what they are currently paying. In many cases, the initial savings could be as much as five percent per year with increased savings over time with satisfactory claims history.

For each application accepted, the malpractice insurance will be provided by one of several insurance companies. These insurance companies, collectively, are licensed to sell insurance in all fifty states in the United States including the District of Columbia and Puerto Rico. One of these companies is a well-known A-rated malpractice insurance company.

Any physician (AAGP Member or Non-member) is welcome to obtain a FREE no-obligation quote to determine just how much he/she could save by obtaining medical malpractice insurance in this program.

To obtain a FREE no-obligation quote on how much your annual premium would be, please complete the following questionnaire and then click on the "SUBMIT" button below. After this questionnaire is processed, your premium quote will be emailed to you with instructions as to how to proceed should you decide you would like to obtain this medical malpractice coverage. (Please allow up to two weeks for a response to your submission.)

* Required Information

Your Name:*
         Last              First              Middle             Suffix    Degree   
Your Address:*
      No.           Street                                            Suite/Apt
Your City:*
Your State:*        Your Zip Code: *
Your Email Address:*
Your Phone Number:*        Your Fax Number: *
Type of Practice:*   Individual Practice
     Group Practice - Number in Group: 
First Practice Date:* Month:    Day:    Year:
Your Specialty/Area:*   General Practice
     Family Practice
     Internal Medicine
     Pediatrics
     Other - Specialty / Area of Practice: 
Current Coverage:*   Claims Made
     Occurrence
Current Insurer:*
Current Limits:*   $250,000/$500,000
     $500,000/$1,000,000
     $1,000,000/$1,000,000
     $1,000,000/$3,000,000
     $3,000,000/$3,000,000
     Other - Amount of Limits: 
Effective Date:* Month:    Day:    Year:
Retroactive Date:* Month:    Day:    Year:
Current Premium:* $   Per Year
* Are You Board Certified by the American Board of General Practice?
Yes
No and I do not intend to become Certified in the future.
No but I do intend to become Certified prior to the following
  date:   Month:    Day:    Year:
* Are You Board Certified by a Board which is a Member Board of
 the American Board of Medical Specialties?
Yes - Name of Board: 
No
* Are You Board Certified by a Board which is Recognized by the
 American Osteopathic Association?
Yes - Name of Board: 
No
* Do you practice part-time (20 hours per week or less)?
Yes
No
* Have you ever been the subject of disciplinary action by any
 state licensing board?
No
Yes
If yes (you have been the subject of disciplinary action by any state licensing board), then please give dates, details and status for each of such actions below:
* Have you ever been involved in a malpractice claim?
No
Yes
If yes (you have been involved in a malpractice claim), then please give dates, details and status for each claim below: 


After you have completed all of the above information, click on the "SUBMIT" button below.


By submitting this questionnaire, you are verifying that all of the above information is true and correct.










* Required Information