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 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



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)



MIEC Acupuncturist Application—Application to insure an acupuncture practice  PDFFillable PDF (Only Use Acrobat Reader to Open and Edit this Fillable PDF)

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

Explanation Re: Hold Harmless Agreements PDF
Guide to Ostensible Partnership
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
DataGuard Increase Limits Healthcare Facilities


HIPAA Material

MIEC uses ZixMail to secure electronic communications. Click here for more information.


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 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).

6250 Claremont Avenue
Oakland, CA 94618-1324
Fax: 510-318-6700

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 to request an application by mail, fax or E-mail.