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Personal Information

First Name

Last Name

Title

State

County

Practice/Organization Name

Number of Physicians

Primary Specialty

Coverage for mid-level providers is only available with physician coverage.

Phone Number

NPI Number(s)

For Medical Professional Liability quotes, enter all Physician NPIs separated by commas

Limits of Liability

How did you hear about us?

Effective Date

Retroactive Date

(for claims-made coverage)

Comments

By submitting this form, you agree to receive email updates from MagMutual. You have the option to unsubscribe at any time. Review our privacy policy for more information. This site is protected by reCAPTCHA Enterprise and the Google Privacy Policy and Terms of Service apply. Occurrence coverage not available in all states. Contact us at 800-282-4882 for coverage availability in NY.