Ortho-Preferred

ORTHO-PREFERRED INDICATION REQUEST FORM

Note: Required fields are marked with an asterisk (*)

Type of Policy

Type of Request* Individual Group

If Group, Name

Personal Details

First Name *

Last Name *

Practice Name

Street Address *

City *

State *

Zip *

County *

Phone

Email *

Contact Preference *

Insurance Information

Are you ABOS certified? * Yes No

Hours worked per week: *

Do you do spine surgery? * Yes No

Specialty *

Type * Surgical Non Surgical

Who is your current carrier? *

What is your current premium?

Limits Requested *

Limits To *

Limits Other

Renewal Date of Professional Liability Insurance

Policy Type* Claims-Made Occurrence

Retro Date (If Claims-Made)

Graduation Date

Residency/Fellowship End Date:

Check this box if you have any claims?

Claims Information

Any claims in the past 10 years?

How many claims?

An Ortho-Preferred representative will contact you to obtain more information on your claims history.

Patient's Name

Date of Service

Date Claim Noticed Received

Date Claim Claim Closed

Was Payment Made on your behalf?

If yes, amount paid

Patient's Name

Date of Service

Date Claim Noticed Received

Date Claim Claim Closed

Was Payment Made on your behalf?

If yes, amount paid

Patient's Name

Date of Service

Date Claim Noticed Received

Date Claim Claim Closed

Was Payment Made on your behalf?

If yes, amount paid

Patient's Name

Date of Service

Date Claim Noticed Received

Date Claim Claim Closed

Was Payment Made on your behalf?

If yes, amount paid

Additional Information

Comments: Please provide any additional information relevant to our review of this information (i.e. prior licensure actions or restrictions, prior insurance non-renewed, etc.)

Additional Comments: ONLY FOR Group Policy (list all physician members)

How did you hear about us?

Security Question Please answer the question below *

Ortho-Preferred is a nationwide professional liability insurance program, exclusively for Orthopaedic Surgeons.

ORTHO-PREFERRED INDICATION REQUEST FORM