Applications and Forms

MIEC Policy Applications & Supplementary Forms

Top Applications & Forms

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


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


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—– Sample Arbitration agreement available for download. 

NOTE: MIEC does not require arbitration for claims processing/resolution, and therefore the use of this agreement by MIEC Members is voluntary.


Increased Limits – Application to increase the coverage limits of the base DataGuard offering. WORD

Specialty Supplemental Applications

Anesthesia PDF

Community Clinic PDF

Emergency Medicine PDF

Fertility Clinic PDF

Imaging Center PDF

Medical Laboratory PDF

Mid-Level/Advanced Provider PDF

Neurology PDF

Obstetrics/Gynecology PDF

Orthopedics PDF

Pain Management/Medicine  PDF

Part-Time Physician/Surgeon PDF

Plastic/Cosmetic Surgery & Procedure PDF

Psychiatry PDF

Surgery PDF

Surgery Center PDF

Urgent Care  PDF

MIEC Specimen Policy Forms

Specimen Policy Forms (Login only)

HIPAA Material


Autopay Authorization Form PDF