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Group Premium Estimate Request

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

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Office Manager Name*:  
E-mail Address*:  
Website Address:  
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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:
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GROUP INFORMATION - part 2 of 3

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

Medical Specialty*:          

Secondary Specialty (if applicable)


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:  

 

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INFORMATION

  800.227.4527

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