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Baxter & Associates, LLC
4400 Bayou Blvd, Suite 52-B
Pensacola, FL 32503

TEL 800.641.8865
FAX 888.287.8894

Chiropractic Professional Liability Insurance
Request for Quote Inquiry
Name:
Contact Person:
Phone Number:
Email Address:
Street Address:  
City:
Which describes your practice?  
Number of years in practice:  
Number hours practice/week:  
Have you had malpractice claims?   Yes No
If yes, list each:  
COVERAGE NEEDS:    
Type of Coverage:  




Proposed Effective Date:  
Proposed Retroactive Date*:   *claims-made only
Proposed Liability Limits:
Specify:
Do you currently have malpractice insurance?   Yes No
If yes, with which company are you insured?
Company:
Comments:


 

 

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