Crosbie-Macdonald Insurance

To receive an medical malpractice insurance quote, please complete the following form.
NOTE: All applicable fields are required.

Name:
Date of Birth:
Address:
City:
State:		Zip:
Phone:
Email:

Would you prefer a return quote by Email? YES NO
Current Coverage: YES NO	Exp. date:

EDUCATION:
School of Graduation:
City:
State:
Country:
Degree:
Year of Graduation:
Specialty
Please choose the option that most closely fits your practice.
Click Here for definitions of No Surgery/Minor Surgery/Major Surgery
Certified by specialty board:	YES NO
Professional Organizations
AMA:	YES NO
MA Medical Society:	YES NO
Other:
Foreign Medical School Only
Certified by education council for foreign medical graduates: YES NO

LIMIT:
Each Claim:
Aggregate:
COVERAGE:
Occurrence Claims Made

For an explanation of the advantages and disadvantages of occurrence coverage vs. claims made coverage please click here or contact John O’Neil at (617)523-4500

PRACTICE:
Type:
Name of Employer (if applicable):
Activities
Surgery: Select applicable procedures from list and indicate percentage total surgical practice.
No Surgery	%
Abdominal	%
Cardiac	%
Colon Rectal	%
General	%
Gynecology	%
Hand	%
Laproscopic	%
OB/Gynecological	%
Laser Surgery	%
Orthopedic (including spinal)	%
Orthopedic (not including spinal)	%
Otorhinolaryngology	%
Plastic	%
Plastic Otorhinolaryngology	%
Urological	%
Vascular	%
Do you assist in Major Surgery on the patients of others? YES NO
If YES, please indicate the percentage of practice:
Please check that all required fields are completed and accurate before submitting the form.

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