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RN/LPN Malpractice Quote

Malpractice Insurance for
RN/LPN

Your Personal Information

First Name *

Last Name *

Street Address *

Apt Number

City

County

State

ZIP / Postal Code *

E-Mail Address *

Telephone

Fax

Professional License # *

Please select

Check your licensure

RN
LPN/LVN
First Year Graduate
National Nurses United

I UNDERSTAND THAT IF I AM A NURSE ANESTHETIST OR CERTIFIED NURSE MIDWIFE, I AM NOT COVERED BY THIS POLICY

CHECK BELOW YOUR SPECIALTY CARE AREA OF PRACTICE AND CHECK IF EARNED CERTIFICATION

Medical/Surgical-general

Certified
Practice

Critical Care-ED/ICU/CCU/Burn Unit etc.

Certified
Practice

OB, L&D, MATERNITY

Certified
Practice

PEDIATRICSM HEMATOLOGY & ONCOLOGY, DIALYSIS

Certified
Practice

BEHAVIORAL HEALTH

Certified
Practice

SURGICAL-OR, PACU, RR DAY SURGERY, ENDOSCOPY, INTERVENTIONAL RADIOLOGY, CARDIAC CATH LAB

Certified
Practice

STEP DOWN-SURGICAL, CARDIAC, TELEMETRY

Certified
Practice

BRAIN TRAUMA/REHAB

Certified
Practice

PLEASE CHOOSE LIABILITY DESIRED BELOW

Please indicate Limits of Liability desired

$200,000/$600,000
$250,000/$750,000
$500,000/$1,000,000
$1,000,000/$6,000,000
$2,000,000/$4,000,000

Please Check the following yes or no

Have you ever been the subject of a reprimand or disciplinary action, or refused employment or admission to a professional society, or had professional privleges suspended by any court or administrative agency.

Yes
No

Has any medical professional or related insurance ever been cancelled or non-renewal?

Yes
No

Reason:

Are you aware of any circumstances which may result in a malpractice claim or suit being made or brought against you? if yes please please attach a separate sheet with full particulars

Yes
No

Please list your prior professional liability insurance if any.

Carrier

Policy Number

Limits

Premium

Effective Dates

THE UNDERSIGNED DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AGREES THAT IF THE INFORMATION SUPPLIED IN THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE(UNDERSIGNED) WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES, AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS, AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE.

SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BSSIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BE ATTACHED TO AND BECOME A PART OF THE POLICY.

NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AND APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.

Applicants Signature:(Type your full name to sign) *

Todays Date *

Title:

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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Zavagno 440-884-2530 and Pavarini 216-374-4500