Professionals' Purchasing Group, Inc.

PPG, Inc.
2904 Eastpoint Parkway
Louisville, KY 40223
E-mail: info@ppginc.net
502-423-7201
800-333-1774
Fax 502-423-7261

Professionals' Purchasing Group, Inc.
Your "One Stop Shop" for
purchasing and practice management support services.

PPG Med-Mal Program ProNational Quick Quote

Physician's Name:	Degree:
Corporation Name:
Practice Address:
City:	State:	Zip:
Practice Manager's Name:
Mailing Address (if different from above):
City:	State:	Zip:
Practice Phone No.:	Fax No.:
PPG Member ID No.:
Physician's Specialty:
Subspecialty (if applicable):
Check one (if applicable): No Surgery Minor Surgery Major Surgery Part-time Num. of hours per week:
Current Insurance Company:
Current Premium: Policy Expiration Date:
Coverage Form: Claims Made: Retro Date:
Occurrence:
Policy Limits of Liability: Years in Practice:
Have you ever been sued or had a claim made against you for medical liability?
If yes, complete the following: Date of Incident: Patient's Name: Is case still open? If closed, show any payment made to plaintiff or show none:
Your email: (must be a valid email address)

For complete applications, visit www.professionalsagency.net.