Lambert, Riddle, Schimmel and Caldwell 3931 University Drive Fairfax, Virginia 22030 703-691-1300 Fax 703-273-4078 www.lambertinsurance.com            email: office@lrscins.com
Premium Indication Information for Medical Professional Liability Insurance Program Name  ( First, Last, Professional Degree): Practice Name:
Requested Effective Date of Policy:
Requested Retroactive Date of Policy:
Requested Limits:
Current Policy Information — please fax a copy of current declarations page to (703) 273-4078
Current Carrier:
Current Policy Expiration Date:   January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Physician Information
Specialty: Board Certified?   Yes No Pending
Surgery Requirements:    No Surgery Minor Surgery Major Surgery
Do you have hospital privileges?   Yes No
Do you have Medical Director Responsibilities?   Yes No
If yes, where? (e.g. hospital, nursing home)
Do you treat patients in a nursing home?   Yes No
If yes, what percentage of your practice?
Do you treat patients in jail or prison?   Yes No
If yes, what percentage of your practice?
Claim Information
Have you been involved in a malpractice claim or suit?   Yes No
If yes, please answer the following:
How many claims or incidents?
When were the alleged incidents?
What were the allegations?
Was the case(s):
Settled?     Tried?    Dismissed?
If settled, what was the payment?
Practice Information
Practice Name:
Mailing Address:
City / State:    County:    Zip :
Number of Physicians in Group:
Number of ancillary personnel (NP, PA, CNM, RN):
Would you like separate limits for corporation?   Yes No
Would you like separate limits for ancilliary personnel?   Yes No
Average number of patients seen per week:
Average number of hours worked per week:
Contact Information
Contact Name:       Office Phone:    Office Fax: