Premium Indication Only Application

Gulf Atlantic Legal Defense Insurance, Inc.

EXPRESS APPLICATION (For a pdf version, Click Here)

General Information
*Denotes required field

*First Name MI *Last Name *MD DO

*Address

*City

*County

*State

*Zip

*Medical License No.

*Date of Birth mm-dd-yyyy

*Email Address

*Home Phone No. 123-123-1234

*Office Phone No. 123-123-1234

Fax No. 123-123-1234

Policy Information

*Date you desire coverage to begin: mm-dd-yyyy

*First Practice Date: mm-dd-yyyy

*Do you desire Prior Acts coverage? Yes No

If YES, retroactive date requested: mm-dd-yyyy

*Do you desire increased limits above the standard $100,000 / $200,000? Yes No

If YES, select desired additional coverage: $25,000 $50,000 $75,000 $100,000

Practice Information

*Does the address provided above represent the only location/facility at which you
provide professional services? Yes No

If NO, please provide the name, address and phone/fax number for each in the area provided below.

*Your Practice Specialty:

Subspecialty:

List invasive procedures which you perform:

Partnership / Corporation / Professional Association Information

Do you practice as:
Partnership Professional Association Solo PA Corporation Other (describe)

If so, name of entity:

*Is this application part of a group application? Yes No

Supplemental Waiver / Release

Any person knowing and with intent to injure, defraud or deceive any insurer files any statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. I hereby certify that the above statements, representations and responses are true, complete and correct, and I understand and agree that you will rely on such statements, representations and responses in making a decision as to whether to issue a policy to me. If the answers contained in the application or this certification materially change during any policy period, I agree to immediately notify you. If transmitted to Gulf Atlantic by facsimile, I agree that the facsimile copy of this application received by Gulf Atlantic shall be, and shall have the same effect for all purposes, as the original. I hereby authorize any person or organization, including attorneys who now or in the past have represented me, to release to Gulf Atlantic any and all information, whether privileged or not, relating to my employment, education, training, hospital privileges (whether granted or not), my malpractice insurance (including but not limited to the underwriting and claims files of any present or former malpractice carrier insuring me), and any and all information which Gulf Atlantic may reasonably request to assist it in underwriting my application for insurance or in administering any claim made against me under my Gulf Atlantic policy.

*I agree that all information entered on this form is correct to the best of my knowledge.

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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