Inquiry Form

www.insurance4docs.com

Bruce R. Swicker . . . "The PROFESSIONAL'S insurance professional"

This fast & easy-to-complete form will provide me with the basic information that I will need in order to contact you.  This form is not an application for insurance; I do not provide "quotes" for professional liability insurance over the Internet.

You may rest assured that any and all information will be held in the strictest confidence, and will never be shared with any third-party.  If, however, you are concerned about the issues of data transmission over the Internet, please feel free to call me directly at 877-320-4061.

  1. Please provide the following contact information:

    Full Name  
    Degree or Title
    Organization
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Phone  
    FAX
    E-mail Address
    Website

  2. Please tell me what type of professional you are:

    Physician or Surgeon (MD or DO)
    Dentist or Oral Surgeon (DDS or DMD)
    Chiropractor (DC)
    Podiatrist (DPM)
    Psychologist (PhD)
    Other (please describe below)

  3. Do you presently carry professional liability ("malpractice") insurance?

    Yes
    No

  4. If the answer is "yes" - when does your policy expire?

    -- mm/dd/yy

  5. Please briefly describe how I might be able to help you?

Copyright © 2002 Bruce R. Swicker, "The professional's insurance professional." All rights reserved.
Revised: June 28, 2002

Bruce R. Swicker, "The Professional's Insurance Professional"
Copyright © 2002 Bruce R. Swicker. All rights reserved.
Revised: 26 April 2002

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