Applications and 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 and acupuncturists.

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 (ONLY USE ACROBAT READER TO OPEN AND EDIT THIS FILLABLE PDF) You will need to login or register to download a fillable PDF. Click the fillable PDF link which will take you to a download page that will force the download of your PDF into your download folder (on a PC that folder is located right below your desktop icon in your documents folder on a Apple it will be in your download folder inside your user folder) Make sure you move the file to your desktop so that you can easily find it. 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 receive a Thank You page in acrobat that will have a link to upload additional supporting documents to the web site (you will need to login).

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

Locum Tenens Physician or Employed/Contract Physician  PDF

Clinic Physician Volunteer/Contractor PDF

 

Partnerships/Corporations

Group Application—Application to insure the liability of medical corporations and partnerships (not for solo corporations) PDFFillable PDF (ONLY USE ACROBAT READER TO OPEN AND EDIT THIS FILLABLE PDF)

 

Acupuncture

MIEC Acupuncturist Application—Application to insure an acupuncture practice  PDFFillable PDF (ONLY USE ACROBAT READER TO OPEN AND EDIT THIS FILLABLE PDF)

 

Non-Physician Providers

Nurse Practitioner PDF
Physician’s Assistant PDF
Non-Physician Healthcare Provider PDF
Nurse Anesthetist PDF
Dental Application PDF

 

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

 

Supplementary Forms

Anesthesiology Restrictive Endorsement PDF
Explanation Re: Hold Harmless Agreements PDF
Guide to Ostensible Partnership
PDF
Keratorefractive Procedure Questionnaire PDF
Spine Surgery Questionnaire PDF
OB Supplement PDF
Pain Management/Procedures Questionnaire PDF
Teletechnology PDF
Total Joint Replacement PDF
Cosmetic Procedures Questionnaire PDF

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 – Save copy to desktop PDF
DataGuard Increase Your Limits 51 doctors or more – Save copy to desktop
PDF
DataGuard Increase Limits Healthcare Facilities
PDF