Applications Center

Request a Premium Indication
Complete and submit a simple worksheet to receive a medical professional liability insurance premium indication within 24 hours.

Note: PMSLIC writes professional liability insurance in Pennsylvania and Delaware only.

Pennsylvania Applicants	Delaware Applicants
Requirements and application files are listed below. Please fax or mail completed applications to the PMSLIC Marketing Department:	For requirements and applications, please contact Willis HRH:
Fax: 717 796-8080	Phone: 302 658-8000
Mail: PO Box 2080 Mechanicsburg, PA 17055-0787	Mail: 300 Delaware Avenue Suite 1600 Wilmington, DE 19899

Application Requirements for Pennsylvania Physicians

Physicians and Surgeons Application
Claims Supplement and Business Associate Agreement
A copy of the Declarations page from the physician's most recent policy if Prior Acts coverage is requested

Application Requirements for Pennsylvania Entities

Professional Corporation and Partnership Application
Claims Supplement and Business Associate Agreement
A copy of the Declarations page from the entity's most recent policy if Prior Acts coverage is requested
A copy of the signed and date stamped Articles of Incorporation

Download Pennsylvania Applications:

instructions

Pennsylvania Applications

To download the Pennsylvania application files, you must have Acrobat Reader installed on your computer. To install Acrobat Reader, click on the icon below to download it from Adobe's Web site.

conventional completion:

print out the application(s)
complete by hand

electronic completion:

download the electronic application(s) to your computer's hard drive
answer all questions electronically by checking the appropriate boxes and filling in the "fields" or blanks
save your changes
print and sign the application

I UNDERSTAND THAT THIS APPLICATION IS SUBJECT TO ACCEPTANCE BY PMSLIC AND DOES NOT BIND COVERAGE.

Please note that the following applications are for Pennsylvania-based medical professionals and practices.

Physicians and Surgeons Professional Liability Insurance application
Claims Supplement and Business Associate Agreement
Professional Corporation and Partnership application
Locum Tenens application
Designated Employee (Allied Professionals) application
(Please note that coverage for designated employees is available ONLY for employees of insured physicians or insured entities.)

If you have any questions, contact PMSLIC's Sales and Marketing Department.

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