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Chiropractors' Malpractice Quote

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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	Claims Made Occurrence No Insurance
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?	Yes No
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:
I would prefer to be contacted:	via email via telephone via fax in the mail
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