Professional Protection - Medical Malpractice Group Renewal Application

Thanks for being a Berxi customer!

We would love the opportunity to continue insuring your medical malpractice group. If you are interested in continuing coverage with us, please complete and submit this secure online application form as soon as possible. To avoid any interruptions in coverage, please submit this form no later than 14 days prior to your policy expiration date.

For your convenience, we have attached your current policy to the email containing the link to this application. Please have the policy open and handy, as it will help you complete this application efficiently.

Contact Information Updates:

Did your business name change in the past year? *

No

Yes

What is your new business name? *

Did the location of your headquarters change in the past year? *

No

Yes

Please enter your new address:

Street Address *

Address Line 2

City *

State *

Zip Code *

Has your mailing address changed in the past year? *

No

Yes

Yes, it's the same as my new headquarter address

Please enter your new mailing address:

Street Address *

Address Line 2

City *

State *

Zip Code *

Your Business Updates:

Your current coverage selections have been sent to you via email from Berxi. If you're unable to find this document, please call 833-242-3794 for help completing this application.

When does your policy expire? * +

Do you want to change the limits on your renewal policy? * 🛈

No, keep the same selections as last year

Yes

I'm not sure

Call 833-242-3794 for assistance completing this application

Select the limit you'd like on your renewal policy: * 🛈

Do you want to add any additional coverages to your renewal policy? (Check all that apply) *

No, keep the same selections as last year

General Liability

Medicare/Medicaid reimbursement

Count of business locations: *

How do you categorize your group? *

Does your group provide services in any of the following practice settings? (check all that apply) *

Does your group work in the emergency department (ED) or intensive care unit (ICU)? *

Yes

No

Does your group provide any of the following treatments or services? * 🛈

Elective hormone therapy to: enhance muscle definition; improve energy, vitality or libido; or enhance aesthetic appearance (not including treatments for birth control, menopause, or transgender care)

Elective IV hydration and/or vitamin injections for purposes such as increasing energy, detox or cleanse, weight loss, or sports performance.

Elective weight loss treatments provided in a weight loss clinic or weight loss center

Ketamine treatments

Medical marijuana treatments or authorizations for medical marijuana

Stem cell injections

No, we do not provide any of the above services

Does your group perform cosmetic or medical aesthetics procedures? *

Yes

No

Please select the below procedures that you provide to patients or clients (Check all that apply to you) *

Please describe the cosmetic/aesthetic procedure: *

Please select the setting(s) in which your group performs these cosmetic or medical aesthetic procedures for patients or clients (check all that apply): *

Does telemedicine or telehealth services make up more than 50% of your group's practice? * 🛈

Yes

No

Does your group prescribe medication containing opioids or narcotics via telemedicine without an in-person examination? *

Yes

No

Do you have knowledge of any circumstance, allegation or incident that could result in a claim, suit or complaint being brought against your group or any individual in your group? *

Yes

No

Has anyone insured with your group had a claim, suit, or board action brought against them (even if the incident did not occur at your practice)? *

Yes

No

Please describe the circumstance, allegation or incident: *

Your Named Insured Updates:

For your convenience, we have attached your current schedule of named insureds list to the email containing the link to this application.

Do you need to make any changes to your named insureds list for your renewal policy? * 🛈

No, keep same as last year

Yes

I'm not sure

Please call 833-242-3794 to confirm your list of named insureds on your application

Do you need to add named insureds to your renewal policy? *

Yes

No

How many named insureds do you need to add to your renewal policy? *

Do you need to remove named insureds from your renewal policy? *

Yes

No

Please list the first and last name(s) of the insured(s) you want removed from your policy for next year: *

Do any of your named insureds require a name change or spelling change? * 🛈

Yes

No

Please provide the original name and the new (or correctly spelled) name: *

Please describe what is incorrect from the named insureds document we sent you: *

Need help? Call 833-242-3794