The Neurologists' Program Malpractice Insurance

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Endorsed by the American Academy of Neurology 

Group Program Information Request Form

Please complete the form below if you would like The Neurologists' Program to contact you regarding coverage for your group practice. All practitioners practicing in a group can be covered under one policy, along with the group practice itself.

You can also obtain information about group coverage by calling (800) 245-3333, ext. 310 or emailing Group@prms.com.

Name*
Address*
City*
State*
Zip*
Email*
Telephone*
Fax
Website
Practice Manager
Renewal Effective Date
Current Retroactive Date

About Your Group

Name of Group
Person Responsible for Insurance Administration
Preferred Method of Contact
How many of the following are in your practice?
Full time Part time
(less than 20 hours)
MDs (Neurologists)
MDs (Other)
Physician Assistants
Nurse Practitioners
Other
Current Premium
How do you pay for your group policy?

In full
Monthly
Quarterly

Type of Coverage Required Claims Made
Occurrence
Type of Practice Neurology (no surgery)
Neurology (minor surgery)
Corporate Coverage Yes - Shared Limit
Yes - Separate Limit
No
Limits of Liability 1M/3M
2M/6M
500M/1.5M
1.3M/3.9M
Other

Areas of Importance to Your Group

Please Check All That Apply:

Risk Management
Claims Handling
Administrative Ease
Consent to Settle

Forensic Coverage
Vicarious Liability Coverage
Online Access for Product
Association Endorsement

* Required Fields
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