Applications and Forms

MIEC Policy Applications & Supplementary Forms

PDF Application Quick Links

Physicians & Surgeons

Physician (Solo) Non-Surgical and Surgical—Application for a Solo Physician in surgical or non-surgical practice PDF

Physician Joining a Group/Corporation/Entity—Application for a Physician or Surgeon applying for an individual policy who is joining a group insured with MIEC PDF

Partnerships/Corporations

Entity/Medical Group Application—Application to insure the liability of medical corporations and partnerships (not for solo corporations) PDF

Acupuncture

MIEC Acupuncturist Application—Application to insure an acupuncture practice  PDF

Informed Consent Form — Sample Informed Consent form for use in an acupuncture practice PDF

Arbitration Agreement

Arbitration Agreement—Optional form available in PDF and printed hardcopies. Must be logged into access page.

Specialty Supplemental Applications

Anesthesia PDF

Community Clinic PDF

Emergency Medicine PDF

Mid-Level/Advanced Provider PDF

Pain Management/Medicine  PDF

Part-Time Physician/Surgeon PDF

Plastic/Cosmetic Surgery & Procedure PDF

Psychiatry PDF

Urgent Care  PDF

MIEC Specimen Policy Forms

Specimen Policy Forms (Login only)

HIPAA Material