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Full name:*
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E-Mail address:*
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Phone numbers:
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Daytime:* |
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| Evening: |
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| Fax: |
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| Best time to contact you? |
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Zip code:*
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| Month / Year you started Practicing Chiropractic |
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*we cannot assist students who have not yet graduated |
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| Current Insurance Information |
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| Current Malpractice Carrier |
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| Renewal Date: |
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| Type of policy in force |
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| Current Limits of Liability |
Each Claim |
| Aggregate |
| Desired Limits of Liability |
Each Claim |
| Aggregate |
| Current Premium: |
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| Retroactive Date: |
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Have you had either a malpractice claim or a professional
board dispute filed against you? |
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| Practice Information |
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Which adjuncts do you utilize in your practice?
*Please check all that apply |
Adjustments
Traction
Electric Muscle Stim
Acupunture
Hair Analysis
Interpertation of diagnostic blood, urine studies
MRI / CT
Cold Laser
Other
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Massage
Heat
Ultrasound
Adjustment of Extremities
Vitamin Injections
Urinalysis
EKG Colon |
Nutrition
Ice
Diathermy
Homeopathy
Iridology
Surrogate Testing
Colon Irrigation |
| Additional information that may help with your quote request. |
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| Please contact me at a future date: |
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| I would prefer to be contacted: |
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| How did you hear about us? |
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