Professional Protection - Healthcare Medical Malpractice Coverage Application

Thanks for being a Berxi customer!

We would love the opportunity to continue insuring your healthcare group. If you are interested in continuing coverage with us, please complete and submit this secure online application form as soon as possible.

Note that your coverage will not automatically continue after the expiration date - so 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.

Current policy expires on: * +

Group Contact Information

Who would you like Berxi to contact regarding your policy?

First Name *

Last Name *

Title

Please confirm your group details:

Group Name *

Group Website Address * 🛈

Email Address *

Phone number *

Group Type? *

Please enter your group's mailing address:

Street Address *

Address Line 2

City *

State *

Zip Code *

Is this the same address as your group's primary business location? *

Yes

No

Please provide the address of your primary business location:

Street Address *

Address Line 2

City *

State *

Zip Code *

Do you have any additional business locations? *

Yes

No

Please enter the address(es) for all additional business locations here: *

0/100 characters

Your Group's Coverage Needs

Please refer to the Declarations Page attached to our email.

Do any of the following policy details require changes? *

Group or business name	First Named Insured
Professional Liability Limits of Insurance	No - these details will stay the same at renewal

Please enter your new group or business name: *

What Each Claim/Aggregate Limits of Insurance are you requesting for your policy? *

Who should be the First Named Insured on the policy? *

Do you need to add any individuals or entities as Additional Insureds (for vicarious liability)? * 🛈

Yes

No

Please confirm the names and addresses for all Additional Insureds to be included on your policy. Note that Berxi requires re-confirmation of all Additional Insureds each year. *

Do you need General Liability coverage? * 🛈

No

Yes, for our primary business location only

Yes, for all business locations (if applicable)

If you have multiple business locations, you must return and enter the location addresses in "Group Contact Information" section of the application.

Do you need Medicare/Medicaid Coverage? * 🛈

Yes

No

Your Group's Healthcare Professionals

Please begin by providing the information for the First Named Insured who will appear on your Declarations Page:

First Name *

Last Name *

Date Joined group * +

Profession *

Specialty *

Average Hours Per Week at Group *

Location (City, State) *

Date of Graduation 🛈 +

How many additional professionals do you need to add? *

Thank you. A Berxi underwriter will be in touch to gather the information about your remaining professionals.

Clinic/Medical Office	Physical Therapy Office
Orthopedic Rehabilitation Office	Mental Health Clinic
Optometry Office	Healthcare Staffing Organization
Occupational Health Service Clinic	Other: Other: