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Get a Quote

Please fill out the information below and we will contact you shortly about your medical malpractice insurance quote request.

Contact Information

Full Name:
Phone:
Fax:
Email:	Required Field
Prefered Method of Contact:	Phone Fax Email
Title:
Specialty/Occupation:

The Practice

Do you do surgery?	Minor Major Don't Know No
Hours worked per week:	Less than 10 10-20 20-30 30-40 More than 40
Years in practice since residency?
Is there a specific company you would like a quote from?

Current Coverage

Company:
Coverage Type:	Claims Made Occurrence
Retroactive date if claims made:	* Important - this determines your tier and affects your proposed rate.
Limits:	per occurrence aggregate
Current Expiration Date: (or date new coverage should start)

Claims Information

Have you been declined for Malpractice coverage in the last 5 years?	Yes No
If yes, which company(s) ?
How many claims have you had in the last 10 years?
How many of these were paid?
What was the total amount of all paid claims, not including legal expenses?

Disclaimer – All information will be emailed on the next business day unless otherwise noted.

Fifth Avenue Physician Services.
4111 S. Darlington Ave. Ste 1200 Tulsa, OK 74169 Office (918)392-7880 Fax (918)355-3439
108 E. 5th Street, Suite B Edmond, OK 73034 Office (405)285-5000 Fax (405)285-5010 Toll Free (800)460-2900