Completed form below is sent to one secure email address only at Ameripa.com 

   -  Please complete the entire form as providing all of the information asked helps develop future programs to benefit independent physician practices.
   -  Your privacy is important to us.  Information is not shared with any third party unless one specifically requests a service such as insurance quotations.
  
  (In certain states, some insurance carriers may apply a specific "risk purchasing group discount" to members.  If this is the case with your offer for insurance, you will be given the option to join the "risk purchasing group" ($25 fee) to be eligible to receive that particular discount.

Requesting Membership only / Med Mal Quote only / or Both

Full Name

Office Phone

Cell or Alternate Phone

Fax #

Address

Suite #

City

State

Zip Code

Office/Practice Manager or Contact Person

Contact Email

Contact Phone #

Medical License #

List all Counties Where You Practice

Practice Specialty

Practice Sub-Specialty

Do You Perform

Type of Practice

Practice Name

# of Physicians in Practice

Number of Physician Assistants and/or Nurse Practitioners

Have you ever had your medical or narcotics license revoked, suspended or placed on probation?

Have you ever had hospital privileges revoked, restricted, suspended or placed on probation?

Have you ever been named in a claim or suit arising from treatment of a patient?

If YES how many total cases?

# of cases where an indemnity payment was made on your behalf

# of closed cases where no indemnity payment was made

# of currently open claims

Do you have knowledge of any incidents that may likely result in you being named in a claim or suit?

Name of Your Current Malpractice Insurance Company

Type of Malpractice Insurance Policy

If Claims-Made what is the retroactive date listed on your policy?

What is the renewal date of your policy?

Annual Premium of your Policy (not including taxes, fees or state fund charges)

Briefly describe any YES answers in the space below.

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