INSURANCE ESTIMATE FOR PODIATRISTS

Full Name*
Preferred Contact Method*
Work Email*
Work Phone Number*
Practice City & State*
Current Policy Expiration Date*
MM slash DD slash YYYY
Claims Made/Retroactive Date*
MM slash DD slash YYYY
Type of Policy*
Limits of Liability*
If Other, What Range?*
Practicing As*
Number of Hours Worked (Per Week)*
Risk Management Course Completed Within The Last 12 Months?
Procedure Mix
Indicate the percentage of time spent annually in the following areas. Procedure Mix total should equal 100%.
Non-Surgical Care (i) (%)*
Diagnostic and therapeutic injections; all nail related procedures, abscess incision and drainage, excision of molluscum contagiosum cysts and other benign lesions, and treatment of ulcers.
Soft-Tissue Surgery?*
Soft-Tissue Surgery (%)*
Osseous Surgery (%)*
Procedure Mix Percentage Total Must Equal 100%
Claims
Please answer the following
Any claim(s) in the last 10 years? (Settled or Pending)*
Claims Settled in the Last 10 Years
Details of all open claims and disciplinary actions*
Details of all closed claims and disciplinary actions*
Surgical Procedures Per Year
Please choose the estimated number of surgeries per year
Ankle/joint/lower Leg Surgery*
Joint or Other Implants or Prosthesis*
Tendon Transfer Surgery*
Anchilles Tendon Surgery*
Laser Surgery*
Minimal Incision Foot Surgery*
Bunion Surgery-Non-Osteotomy*
Bunion Surgery-Osteotomy*
Hammertoe Surgery*
Cryosurgery/Chemosurgery*
Amputation*
Arthoereisis*
Other (Describe)*
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Procedure Mix