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. If you wish to provide coverage for your corporation or for others under your direct supervision, or you wish to take adavantage of our most utilized endorsements, Legal Defense and Medicare/Medicaid, please complete the "Additional Coverages Form."

Applications Form

A fill-in pdf version of the full application for the Legal Defense Expense Insurance Policy. Requested information includes practice details, prior or current insurance information, education, and past/current claims.

Claims Form

Required should you have been a party to a settled claim within the past ten years or have an open pending claim. A separate form is requested for each claim, medical incident, ACHA or any other action against your license.

Prior Acts Form

The Prior Acts form is required when requesting a retroactive date prior to the effective date of your policy.

Additional Coverages Form

Please download the Additional Coverages form should you desire to add these common additional endorsements to your policy: Medicare / Medicaid Defense, Legal Defense, Vicarious Liability.

Premium Indication Form

If you are looking for a quick and easy application form to submit to our underwriters for review, please download our premium indication form.

DH-MQA 1014 (Dept of Health, Board of Medicine /Financial Responsibility)

Provided by the Florida Department of Health Board of Medicine, this Financial Responsibility form is required of any physician who has decided to go "bare".

Payment Options / Credit Card Authorization Form

View the flexible premium payment options Gulf Atlantic offers. Use this form to authorize premium payments via a credit card – either a single payment or a convenient recurring payment.