National Agency - Baxter & Associates LLC Phone: (800) 641-8865 • Fax: (888) 287-889 • •


[ ] Policy Application

Related Quote ID: -   |   Received:
Application Details
Status Underwriting Application ID U- Annual Premium CUSTOM QUOTE
Preferred Payment Option TBD Financing Deposit N/A Payment Status N/A
Basic Information
Applicant Name (First, Middle, Last) Date of Birth
Phone Number Email Address
Professional Designation () License No
National Provider Identifier (NPI) Solo Corporation N/A
Practice Address
Mailing Address
Coverage Information
Requested Effective Date01/01/1970 12:01 am Local Time Requested Retro DateN/A
Limits N/A Coverage Add-Ons General Liability ($1,000,000/$3,000,000)
Supervising/Collaborating Physician
Position Type OwnerEmployeeIndependent ProviderIndependent ContractorOther
Practice Type Individual Exiting Liability Insurance CarrierN/A
Practice Area
Practice Information
Practice Hours Full Time (more than 20 hours per week)
Non-Invasive Specialties
Surgical / Invasive Specialties
Additional Practice Specialty Notes
1 Assisting in Surgery: N/A
2 Emergency Unit/Medicine/ER:
3 Weight Loss Medicaton:
4 PRP Administration:
5 Medical Marijuana, Hormone Pellets, Suboxone:
6 More than 25% of practice include Nursing Home, Assisted Living, or Skilled Nursing Facility exposure? N/A
7 Cosmetic/Astethic Setting: N/A
8 Pain Management Services: No
9 Obstetric Services: No
Supplemental Questions
1 Has Any Professional Liability Insurance Company Ever Canceled, Non-Renewed Or Modified (E.G., Involuntarily Reduced Limits, Restricted Coverage, Added A Deductible And/Or Surcharge, Etc.) Your Insurance, Declined To Offer You Coverage Or Notified You Of Its Intent To Pursue Such Action?
2 Has Your License To Practice As A Health Care Professional In Any Jurisdiction, Your DEA Registration, Or Any Applicable Controlled Substance License Or Registration In Any Jurisdiction Ever Been Denied, Restricted, Suspended, Revoked, Not Renewed, Voluntarily Or Involuntarily Surrendered, Fined, Subject To Probationary Terms Or Conditions Or Otherwise Investigated Or Limited In Any Way?
3 Has Any Governmental Agency Ever Investigated You, Placed You On Probation, Suspended You Or Taken Any Action Against You?
4 Have Your Clinical Privileges, Memberships, Contractual Participation In Or Employment By Any Medical Organization (E.G., Hospital Medical Staff, Medical Group, Independent Practice Association (IPA), Health Plan, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Payer (Including Those That Contract With Public Programs), Medical Society, Professional Association, Medical School Faculty Position Or Other Health Delivery Entity Or System), Ever Been Denied, Restricted, Suspended, Revoked, Not Renewed, Voluntarily Or Involuntarily Surrendered, Subject To Probationary Terms Or Conditions Or Otherwise Investigated Or Limited In Any Way For Possible Incompetence, Improper Professional Conduct Or Breach Of Contract, Or Is Any Such Action Pending?
5 Have You Ever Surrendered, Allowed To Expire, Voluntarily Or Involuntarily Withdrawn A Request For Membership Or Clinical Privileges With; Terminated Contractual Participation Or Employment In; Or Resigned From Any Medical Organization (E.G., Hospital Medical Staff, Medical Group, Independent Practice Association (IPA), Health Plan, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Payer (Including Those That Contract With Public Programs), Medical Society, Professional Association, Medical School Faculty Position Or Other Health Delivery Entity Or System) While Under Investigation For Possible Incompetence, Improper Professional Conduct Or Breach Of Contract, Or In Return For Such An Investigation Not Being Conducted, Or Is Any Such Action Pending?
6 Have You Ever Been Convicted Of Or Admitted To Committing A Misdemeanor, Including A DUI, But Excluding Minor Traffic Violations?
7 Have You Ever Been Charged With, Been Convicted Of Or Admitted To Committing A Felony?
8 Have You Ever Been Accused Of Sexual Misconduct?
9 Have You Ever Had Any Contact Of A Sexual Nature With A Patient Or A Former Patient?
10 Have You Ever Had A Problem With, Been Evaluated For, Been Diagnosed With, Been Treated For Or Are Currently Being Treated For Alcohol, Narcotic Or Any Other Substance Addiction, Sexual Addiction Or Mental Illness?
11 Do You Have Any Health Problem, Illness Or Physical Condition That Impairs Or Could Tend To Impair Your Ability To Practice?
Claims Information
1 Within The Past Seven (7) Years Has A Malpractice Claim Or Suit Been Brought Against You, Or Have You Been Notified Of Your Involvement In A Malpractice Claim Or Suit, Either Directly Or Indirectly?
2 To Your Knowledge, Within The Past Seven (7) Years Has A Malpractice Claim Been Brought Against Any Organization (E.G., Medical Group, Hospital, Etc.) As A Result Of Your Rendering Or Failing To Render Professional Health Care Services?
3 Are You Aware Of Any Medical Incident Or Accident, Conduct, Circumstance Or Occurrence That Might Reasonably Be Expected To Give Rise To A Claim Or Suit Against You, Directly Or Indirectly, Even If You Believe The Claim Or Suit Would Be Without Merit?
Policy Terms

Coverage for this program is underwritten by COPIC Risk Retention Group (RRG), rated A “excellent” by AM Best. COPIC RRG is not part of any state guaranty fund, and may not be subject to all laws and rules in your state.

Prior Acts Statement

I understand that the Medical Malpractice Insurance Policy I am purchasing does not include prior acts coverage. This policy will not cover any incidents, claims, or acts prior to the policy effective date.

Minimum Earned Premium

Policy is 25% minimum earned premium and any policy fees are 100% earned. Once the policy is bound you agree that if you cancel that the company will keep a minimum of 25% of the premium and all of any policy fee.

Electronic Signature Consent Notice

I understand that by typing my name in the electronic signature field(s) within this form, I am providing my electronic signature, and I consent to the use of my electronic signature on this application. I am aware that the date and time of my electronic signature will be recorded and associated with my application. I acknowledge that my electronic signature is the legal equivalent of my handwritten signature and I consent to be legally bound to all the terms and conditions outlined on this application.

Electronic Signature → Signed:
Warranty Statement

The Applicant understands and agrees that all information contained in the application(s) and supplemental information submitted to COPIC in connection with the insurance being applied for will be relied upon by COPIC underwriters in issuing the policy and are the basis for the proposed insurance. Such application(s) and information submitted to COPIC shall be deemed attached to, and made a part of, this Warranty Statement.

The Applicant also understands and agrees that the policy, for which this Warranty and application are made subject to its terms and conditions, does not apply to claims or potential claims the Applicant is aware of, or should be aware of after reasonable inquiry, prior to the effective date of coverage. All claims or potential claims including but not limited to fetal demise, maternal death, shoulder dystocia, severe infection, delayed delivery, misdiagnosis/ delayed diagnosis, surgical error, unexpected significant adverse outcome and significant medication errors should be reported to the Applicant’s current carrier. Similarly, and without limiting the foregoing, given the COVID-19 pandemic, the Applicant further understands and agrees that such policy does not apply to any COVID-19 claim or potential COVID-19 claim prior to the effective date of coverage, such as deaths, and such claims or potential claims should be reported to its current carrier.

The Applicant warrants, after reasonable inquiry, that it is not aware of any dispute, error, omission, act or circumstance that is, or could reasonably be expected to become, a claim under the policy of which the application(s) and supplemental information are submitted to COPIC, including, but not limited to, an attorney’s request for records, patient/family dissatisfaction, or unanticipated death/paralysis/disability.

  1. By signing below, the Applicant warrants that the foregoing is true and complete and acknowledges that the insurer is relying on the accuracy of this statement in acceptance of the risk.
  2. The Applicant acknowledges and agrees that this warranty statement shall be the basis of the proposed insurance and shall be considered incorporated into and constituting part of the proposed insurance.
  3. The Applicant agrees that if the information supplied on this warranty statement changes between the date of the warranty statement and the inception date of the insurance, the Applicant will immediately notify the insurer of such a change, and the insurer may modify or deny coverage.
Electronic Signature → Signed:

I understand that this is an application for insurance and not an insurance binder! I understand and agree that as a condition of being insured, I accept the requirement to submit to a health and skills assessment by a physician of COPIC’s choice. This assessment may be required at COPIC’s discretion.

I understand that I am not applying for coverage in any state patient compensation fund, including but not limited to Pennsylvania Patient Compensation Fund (MCare), Wisconsin Injured Patients and Families Compensation Fund, Kansas Health Care Stabilization Fund, Indiana Patient Compensation Fund, Louisiana Patient Compensation Fund, New Mexico Patient Compensation Fund, Nebraska Excess Liability Fund, South Carolina Patient Compensation Fund, or the New York Excess Coverage Fund.

I hereby declare and warrant that all answers and statements herein given are true and complete to the best of my knowledge and that no material fact or circumstance concerning the subject matter of this application has been omitted or withheld. I understand that these answers and statements are material and as such will be relied upon in the determination by the company to grant my liability insurance. If I or any other person making application or providing information on my behalf misstate or fail to disclose any pertinent information, my application may be declined. If my application is approved and it includes any misstatement or failure to disclose pertinent information, COPIC has the right to cancel my insurance. COPIC also has the right to decline coverage for a specific claim if COPIC would have declined to issue insurance or limited my coverage if I had not made the misstatement or omission.

Further, I recognize and agree that as a prerequisite to acceptance of this application and consideration for granting of liability insurance, COPIC and/or its assigns may conduct a peer review investigation of me and/or my practice. As part of such peer review investigation, I consent to the release of any prior Practice Quality Report and to periodic chart and medical record reviews conducted by Practice Quality, as COPIC may request or direct. I agree to abide by any recommendations arising from that review. I have been provided, understand, and will comply with the Participatory Risk Management Guidelines of COPIC.

I authorize any state board of medical examiners or licensure, hospital board or committee, hospital records department, insurance company, professional society, past or present, business or medical associate or private person that may have any record or knowledge concerning any of the answers or statements made herein to release such information to COPIC or its assigns. I authorize the use of a copy of this authorization in lieu of its original.

As may be permitted by law and in compliance with COPIC policy, I hereby consent to COPIC’s release of the following information about me to credentials verification organizations, health plans, hospitals, health care organizations, professional liability insurance carriers, and state and federal regulatory entities, including but not limited to boards of medical examiners, the National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank and to the fullest extent permitted by law, hereby release all providers of such information, including COPIC, its employees and agents, from any and all liability therefore. This release applies to the following information: my name, business address, social security number, NPI number, license number, hospital affiliations, policy numbers, effective dates, limits of liability, retroactive date, specialty, PLI rate class, and any information concerning those claims which are required to be reported to any state board of medical examiners or medical licensing body or authority, National Practitioner Data Bank and/or the Healthcare Integrity and Protection Data Bank.

Electronic Signature → Signed:
Superseding Clause

By submitting an application for coverage, you acknowledge and agree that the terms, disclaimers, warranties, provisions, agreements, and content specified within this application shall supersede and prevail over any conflicting or contradictory terms presented on this website. The terms outlined in this application for coverage will govern the contractual relationship between you and BaxterPro (Baxter & Associates) and COPIC RRG concerning the coverage applied for.


Insurance fraud is committed when a person knowingly and with intent to defraud or deceive supplies false, incomplete or misleading information concerning any fact or thing material to an insurance policy. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any person who knowingly attempts to commit insurance fraud is subject to civil action by the Company and shall be reported to the appropriate law enforcement authority.

Proxy For RRG Applicants

In consideration of the COPIC RRG’s issuance of insurance to the Applicant, the Applicant hereby constitutes and appoints the Chairman of the Board of COPIC RRG as the Applicant’s proxy to attend all meetings of the members of COPIC RRG, with full power to vote as proxy for the Applicant and act in the Applicant’s name, place and stead, in the same manner, to the same extent, and with the same effect that the Applicant might if personally present, giving to the Chairman of the Board full power of substitution. This grant of a proxy shall continue in force indefinitely until either (1) the Applicant ceases to be a policyholder of COPIC RRG or (2) the Applicant revokes the proxy.

Electronic Signature → Signed:
Digital Document Delivery Notice

As a participant in this program, you will receive all documentation, including, but not limited to, policy documents, payment receipts, policy certificates, and other related materials through electronic means, such as download links, web pages, emails, or PDF files. By accepting electronic documentation, you affirm that you possess a device or computer system that meets the necessary requirements for such access. It is your responsibility to download and securely store all documents provided to you via this website or email transmission.

Electronic Consent → ◉ Yes, I agree to the digital delivery notice, privacy policy and terms of use of BaxterPro.