For Healthcare Professionals (Allied Personnel)


Agent name: Mike Grady
Address 1: 1850 Forest Hill Blvd, Suite #101
City: West Palm Beach State: FL Zip: 33406 Phone: 561-540-8017 Fax: 561-540-8650 E-mail:


Application Instructions and Checklist

Prior to completing the attached application, please read and observe the following instructions. Please verify that all required attachments are included in order to assist us in processing your application promptly and efficiently.

  • Please complete this form electronically or print your responses legibly.
  • Please sign and date the application where indicated.
  • All information requested must be fully and accurately completed.
  • If changes or corrections must be made to the completed application, strike out or line through the incorrect information, write in the modification, and initial and date the change.
  • If a particular question does not apply to you, please write “N/A.”
  • The Medical Procedures questionnaire must be completed. If the procedures you perform are not mentioned in the questionnaire, please list them in the Remarks section.
  • If you wish to explain any of your answers, please use the Remarks section. If you need additional space, please continue your answers on your letterhead and attach it to the application.
  • Claims information should be provided for a five-year experience period. This applies to open and closed claims and to any incidents reported to a previous carrier. It is important that you provide complete and detailed claims information, including current company loss runs.


Required Attachments

Please include a current copy of the following documents with the application:

  • Your most current, updated curriculum vitae (CV). If it does not reflect your current training, practice, certificates, etc., please include an addendum.
  • Declarations Page from your current policy, showing your policy period, limits of liability, retroactive date, and any exclusions that were applied to your policy.
  • Loss runs from all insurance carriers that insured you for the past six years (if applicable).
  • Certificates of training for cosmetic procedures (if applicable).
  • Practice protocols.

    Except to the extent as may otherwise be provided in the policy and its endorsements, the coverage of a claims- made policy is limited generally to liability for only those claims that are first reported in writing to the Company while the policy is in force.

    Insurance coverage is subject to underwriting approval and payment of the premium. No coverage exists until the premium is received and a binder or coverage summary, together with any endorsements that may apply, has been issued to the first named insured.

    Claims-made vs. occurrence: Claims-made policies generally cover incidents and events that both happen and are reported to us while you have a policy with The Doctors Company. You may request a retroactive date to allow you to report to us claims that arise out of incidents that took place previously while you were insured elsewhere. You can also purchase extended reporting, or tail, coverage which will allow you to report claims that arise out of incidents occurring after your retroactive date but before you ended your policy with us, but which are reported after you end your coverage with us.

    Occurrence policies cover incidents that happen while you were covered by a policy issued by The Doctors Company, but can be reported anytime (even if you no longer have a policy with us).

    In some states we offer a third option claims-made with a pre-paid extended reporting period (ERP) endorsement, also known as tail coverage. This option works a lot like an occurrence policy and the cost of the tail coverage is included in your claims-made premium.

    If you need additional forms or have any questions about the application, please contact your broker/agent, or call The Doctors Company Member Services at 800.421.2368.


Please indicate coverage type desired:

1. Claims-made (available in all states). Covers incidents that take place after the retroactive date and are reported during the policy period.
2. Occurrence (only available in IN, MI, NM, NY, PA, and SC). Covers incidents that take place during the policy period regardless of when reported as a claim.
3 Claims-made with a extended reporting period (ERP) endorsement, also known as tail coverage (only available in IL, MA, MI, and OH).
Please list all office locations and entities for which you are requesting coverage. Please indicate if they are: hospital, medical office, surgery center, nursing home, urgent care center, correctional facility, etc.
If prior acts coverage is not being requested, are you purchasing extended reporting period (tail) coverage from your prior carrier?
Please indicate your average number of practice hours per week that will be covered by this policy including office hours, administrative activities, direct patient care, surgery, consultation, etc. (excluding on-call), and Estimate the number of patients seen on an average weekly basis: