APPLICATION INFORMATION

You may download an application, claims or prior acts form by clicking on the "PDF" links below. You will need to complete the "Claims Form" if you have been a party to a settled claim within the last ten years or have an open pending claim. You will need to complete the "Prior Acts Form" if a retro active date is requested.

Click here to download the Application

Click here to download the Claims Form

Click here to download the Prior Acts Form

Click here to download the Additional Coverages Form

Click here to download the Express Application Form

Click here to download form DH-MQA 1014 (Dept of Health, Board of Medicine /Financial Repsonsibility)

Download Adobe Acrobat Reader

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Post Office Box 12200 (32317-2200) * 2549 Barrington Circle * Tallahassee, Florida 32308
LOCAL T) 850.385.8555 F) 850.385.1657 * TOLL FREE T) 800.839.2944 F) 800.357.0652