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Chiropractors' Malpractice

Chiropractors' malpractice
* Required Information

Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Full name:*
    
E-Mail address:*
Phone numbers:
Daytime:*
Evening:
Fax:
Best time to contact you?
Zip code:*
Month / Year you started Practicing Chiropractic
  *we cannot assist students who have not yet graduated

Current Insurance Information  
Current Malpractice Carrier
Renewal Date:
Type of policy in force

Current Limits of Liability Each Claim
Aggregate
Desired Limits of Liability Each Claim
Aggregate
Current Premium:
Retroactive Date:
Have you had either a malpractice claim or a professional
board dispute filed against you?

Practice Information  
Which adjuncts do you utilize in your practice?
*Please check all that apply

Adjustments
Traction

Electric Muscle Stim
Acupunture
Hair Analysis
Interpertation of diagnostic blood, urine studies
MRI / CT
Cold Laser
Other

Massage
Heat

Ultrasound
Adjustment of Extremities
Vitamin Injections
Urinalysis
EKG Colon
Nutrition
Ice

Diathermy
Homeopathy
Iridology
Surrogate Testing
Colon Irrigation
Additional information that may help with your quote request.

Please contact me at a future date:
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