Physician & Surgeons | Partnerships/Corporations | Acupuncture | Employees | Healthcare Facilities | Supplementary Forms | MIEC Policy Forms
For your convenience all of our applications and forms are downloadable PDFs. We now also offer a fillable PDF version for physicians joining a MIEC insured group.
1. PDF — You can download any PDF application onto your desktop. You can print it out and fill it in manually, then mail it, scan then email it or fax it to MIEC at the address, email or fax below:
2. Fillable PDF — You will need to login or register to open a fillable PDF. Make sure you save it to your desktop right away. You can fill out the PDF and save it as you go. When you are done and click the submit button the PDF will automatically upload to miec.com. If an allow button comes up, please click it in order to let your PDF upload to our web site. Once your PDF is uploaded you will have the opportunity to upload additional supporting documents.
MIEC
6250 Claremont Avenue
Oakland, CA 94618-1324
Fax: 510-318-6700
underwriting@miec.com
These PDF forms require a free copy of Adobe© Acrobat Reader to download and print them out. Click here to download a free copy of Acrobat Reader now.
If you don't have Acrobat Reader and don't wish to download it, you may call 800-227-4527 or email underwriting@miec.com to request an application by mail, fax or E-mail.
Physicians & Surgeons
Physician (Solo) Non-Surgical and Surgical—Application for a Solo Physician in surgical or non-surgical practice PDF | Online Application
Physician Joining a Group/Corporation—Application for a Physician or Surgeon applying for an individual policy who is joining a group insured with MIEC PDF | Fillable PDF
Locum Tenens Physician or Employed/Contract Physician PDF
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Partnerships/Corporations
Group Application—Application to insure the liability of medical corporations and partnerships (not for solo corporations) PDF
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Acupuncture
MIEC Acupuncturist Application—Application to insure an acupuncture practice. PDF
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Employees
Clinic Physician Volunteer/Contractor PDF
Dental Application PDF
Employed Acupuncturist PDF
Locum Tenens Physician or Employed/Contract PDF
Nurse Practitioner/Physician’s Assistant PDF
Non-Physician HealthCare Provider PDF
Employed Nurse Anesthetist PDF
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Healthcare Facilities
Blood Bank Application PDF
Urgent Care Center PDF
Emergency Contract Group PDF
Community Clinic PDF
Sleep Center PDF
Diagnostic Outpatient Facility PDF
Surgical Outpatient Facility PDF
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Supplementary Forms
Anesthesiology Restrictive Endorsement PDF
Guide to Ostensible Partnership PDF
Keratorefractive Procedure Questionnaire PDF
Spine Surgery Questionnaire PDF
OB Supplement PDF
Pain Management Questionnaire PDF
Teletechnology PDF
Cosmetic Procedures Questionnaire PDF
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MIEC Policy Forms
Added Legal Defense Coverage—Part IV (Optional) Coverage PDF
Making Changes to Your Practice ONLINE FORM (Login only)
Increase Your Professional Liability Limits PDF
DataGuard Increase Your Limits Up to 50 Doctors PDF
DataGuard Increase Your Limits 51 doctors or more PDF