Physicians Professional Indemnity Association (PPIA)

NEWS:

Name of Physician:
Group Membership:
Principle Office Address:
City, State:	,
Zip Code:
Office Telephone:
Office Fax:
Proposed Effective Date:
Retroactive:
Amount of Insurance Desired:
$100,000/$200,000	$100,000/$300,000
$200,000/$400,000	$200,000/$600,000
$500,000/$1,000,000	$500,000/$1,500,000
$1,000,000/$2,000,000	$1,000,000/$3,000,000
Other
Type of Practice
Solo Practitioner	Partnership
Professional Association	Professional Corporation
Place a check mark beside any of the following procedures, which you perform
Anesthesiology	Pathology
Cardiovascular Surgery	Pediatrics
Emergency Medicine	Plastic Surgery
Family Practice - No OB/GYN	Pulmonary Disease
Gastroenterology	Radiology
General Surgery	Rheumatology
Internal Medicine	Thoracic
Neurology	Urology
OB/GYN	Vascular
Oncology Orthopedics - No Spine Orthopedics - With Spine	Other Surgery - Explain:
	Other Specialty - Explain:
	IPA/IPO Membership: