Request for ESTIMATED PREMIUM
Please Note: This is only a Request for ESTIMATED PREMIUM. A formal binding quote will only be issued after submission of a complete PPIR Application and full underwriting. To apply for insurance coverage, please contact your Broker or the Physicians Preferred Underwriting Department at 904-332-7841.
 
 Contact Information 
 
Name: 
Address:
City:
State:
Zip:
Telephone:
Fax:
Cell:
Email Address:
 
 Practice Information 
 
Name of Primary Contact in your office:
County of Practice:
Specialty for which you want coverage:
Board Certified in Specialty?
How Long in Practice?
How Long In FL Practice?
Requested Limits of Liability:
Effective Date Requested:   (MM/DD/YYYY)
Retroactive Date:   (MM/DD/YYYY)
Current Insurance Carrier:
Claims history: I have been Claims Free for
(count a Claim if $50,000 or higher):
How did you hear about Physicians Preferred?