K&B Underwriters

Medical Malpractice Indication Form

Please provide us with the following information and we'll contact you within two business days with an indication.

For an indication for allied healthcare personnel, hospitals and other healthcare facilities, and alternative risk transfer programs, please call us at (888) 760-3194 or contact us via e-mail at medmalinfo@kbunderwriters.com.

Agency Information Broker first name

Broker last name

Broker email (required)

Broker phone (required)

Agency Name

Street

City

State

Zip

Liability Information Account

Effective date

Retro. date

Current limits of liability

Current carrier

Specialty

Do you perform surgery?

If yes to above, minor or major?

What is your primary practice location?

Do you practice in other states?

If yes, please indicate % of practice:

Have you had any claims greater than $10,000 paid in the last year?

Number of years in practice?

Comments/Description

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