Application for Physicians and Surgeons
Professional Liability Insurance
Claims Made Basis

APPLICANT'S INSTRUCTIONS

Please answer all questions.  Provide us with information so we can give you a quote for your desired insurance. Please read carefully the statements at the end of this application.  Please do not complete application earlier than 45 days before proposed effective date of coverage.  If you have Cirriculum Vitae (C.V.) please let us know and send it to us after you speak with the Binney, Chase & Van Horne agent.   This is a 6-part form application. You will finish each form and then proceed to the next form. On each form, above the submit button is a section where you can further explain or clarify any answers you have given on each form. Important: You must NOT use your browser's BACK button to review previous pages or you will have to start at the first form again. Thank you!

Your Name & Email Address Your first Name: (required) Your Last Name: (required) Your E-mail Address: (required) E-mail Address Again: (required)

After you enter your name and email address, click the below button to go to Step 2.