Section 18 Excess Professional Liability Insurance Application

Protect yourself and your personal assets
**Apply for FREE Section-18 Excess Coverage**

What is Excess Coverage?

It is an additional $1 million of coverage per claim and $3 million over the annual aggregate on top of your primary malpractice limits.

Participating hospitals have limited slots available so act quickly.*

*Doctors new to the section-18 excess program will be waitlisted pending hospital approval.

If you already have Excess insurance through another carrier, please contact us and find out why it makes sense for you to switch to PRI.

For any question, please call 1-800-632-6040
Or E-mail us at: Underwritingcontacts@medmal.com

Apply Here

Please check one: *

New Excess Policy with EmPRORenewal of EmPRO Excess Policy

Name *

Email *

EmPRO Policy Number *

Primary Affiliated Hospital *

If you are changing Section 18 excess insurance from another carrier, please provide the name of the other carrier

If this is a new application or if you are changing Section 18 excess insurance from another carrier, please indicate the date when you would like your coverage to begin

I authorize release and exchange of information, involving but not limited to claim matters, between my professional society or association, previous insurance carrier, hospital or clinic and EmPRO.

Yes

Physicians must complete a risk management course every 2 years to maintain their excess insurance. If you have taken a course with another carrier, please submit proof of completion. If you take courses with EmPRO, we will check whether you are up to date with your risk management course completions. If your credit has expired or is due to expire, EmPRO will notify you that you need to complete a course.

NOTE: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

Electronic signature - Type name below *

Date of signature *

By checking this box, I understand that I am signing this application electronically. I understand and agree that the electronic signature is the equivalent of my handwritten signature. *

Yes