Contemporary Insurance Services: Certified Nurse-Midwife Questionnaire

Contact Information

First Name:
Last Name:
Title:
Address:
City:
State:
Zip Code:
Email:

Malpractice Insurance Information

Specialty:	Please send additional information concerning malpractice insurance for the specialty of
Contact:	Please contact the following person to set up an appointment or discuss this program:
	Name:
	Title:
	Phone:
Insurer:	My current malpractice insurer is:
Start Date:	The date I first entered practice is: (mm/dd/yyyy)
Claims:	Have you ever had a Malpractice Claim against you (include cases decided in your favor)?
	No	I have been claims free for years.
	Yes	closed with a payment closed without a payment are pending If no cases pending, date last case was closed:

Also, please send information concerning:

Term Life Insurance:			Term life insurance premiums have been recently reduced. It pays to compare. You may be able to lower your premium or get more of longer coverage at the same price.
Birthday:	Male	Female
	Smoker	Non-Smoker
Amount of Coverage desired:

Long-Term Care Insurance:			Policies differ from company to company. For example, if you intend to retire outside the U.S., only a few companies will pay long term care benefits.
Birthday:	Male	Female
Spouse's Birthday:	Smoker	Non-Smoker

Disability Insurance:			Own occupation coverage and higher monthly limits are back. It pays to review your policies.
Birthday:	Male	Female
	Smoker	Non-Smoker
Specialty:	Desired Monthly Benefit:

Submit

Please review the information entered in the form. If the above information is correct, press the "Submit" button below to complete your form submission.


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