GROUP QUOTE

Please provide us with information so that we can give you a group quote.
Be sure to fill in all the required fields.

These fields are required*

GENERAL INFORMATION - part 1 of 3

Office Manager Name*:
E-mail Address*:
Website Address:

Mailing Address

Street Address*:
City*:
State / Region*:
Zip*:
Phone*:
Current Carrier:

If other, please specify:
How did you hear about MIEC insurance?
If other, please specify:

GROUP INFORMATION - part 2 of 3

Group Name*:
Practice Location*:
City*:
State / Region*:
Effective Date*:
Limits of Insurance*:

	Comments/questions:

PHYSICIAN INFORMATION - part 3 of 3

In this section, fill in information for up to 10 physicians. If you would like a premium estimate for more than 10 physicians in your group practice, please contact MIEC’S Underwriting Department at: 800.227.4527 or underwriting@miec.com.

Physician 1

Name*:

Medical License #*:

Limits of Insurance*:

FullTime PartTime

Medical Specialty*:

Secondary Specialty (if applicable)

This physician does not want retroactive coverage.
Retroactive Date:

If this physician completed his/her training program within the last 3 years,
please tell us the date he/she started seeing patients:
Practice Start Date:

INFORMATION

800.227.4527

GENERAL INFORMATION - part 1 of 3

Mailing Address

GROUP INFORMATION - part 2 of 3

PHYSICIAN INFORMATION - part 3 of 3

Physician 1

INFORMATION

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