Medical Insurance Exchange of California - Professional Liability Insurance

Serving Alaska, California, Hawaii and Idaho

The application and supplemental forms below are in PDF format which requires Adobe© Acrobat Reader for viewing and printing. Click on the icon to download 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.

Complete the appropriate forms and mail or fax to MIEC

MIEC
6250 Claremont Avenue
Oakland, California 94618-1324
FAX: 510-654-4634

APPLICATIONS: If you are unclear as to which application you should complete, please contact us
Joining Group/ Entity Affiliation Application (Physicians and Surgeons) an application for a Physician or Surgeon applying for an individual policy and is joining a group that is already insured with MIEC
Solo Physician - Non-Surgical Practice Application an application for a Solo Physician in a non-surgical practice
Solo Physician – Surgical Practice Application an application for a Solo Surgeon
Group Application an application to insure the liability of medical corporations and partnerships (not for solo corporations)

SUPPLEMENTAL FORMS: Please complete and include with your application any of the following supplemental forms that are appropriate:
Supplement to Application for OB Practice Coverage required for all obstetricians and family physicians who include obstetrics in their practice
Anesthesiology Restrictive Endorsement required for all anesthesiologists who apply for MIEC coverage
Employed Nurse Anesthetist (CRNA) Questionnaire required for all employed certified registered nurse anesthetists
Orthopedic Questionnaire required for all orthopedic surgeons who perform spine surgery and total joint replacement procedures
Short Form Application for Employed/Contract Physician or Locum Tenens to be completed by part-time and temporarily employed physicians
Nurse Practitioner/Physician's Assistant Questionnaire required for employed nurse practitioners and/or physician's assistants
Making Changes to Your Practice required for employed nurse practitioners and/or physician's assistants
Non-physician Healthcare Provider Application for other employees, such as psychologists, social workers, etc
Added Legal Defense Coverage for medical practice business risks - "Part IV Coverage"
Making Changes to Your Practice an easy way to report employee, partnership and/or address changes
Increase Your Professional Liability Limits if you want to increase your professional liability insurance limits