MembershipPreliminary Application for Membership

Become a member-owner and join a national medical malpractice insurance leader.

A nationwide network of independent brokers available.

Complete the preliminary application for membership below. An independent medical malpractice insurance broker will contact you once the completed application is received and provide you with a quote to become a member-owner of Oceanus Insurance.

General Information

Your Contact Information

First Name:*

Last Name:*

Your E-Mail Address:*

Website:

Information about your Practice

Primary Practice Address:

City:

County:

State:

Zip:

Office Phone:

Office Fax:

Practice Information

Individual

Partnership

Other 

Group Practice

Professional Corporation

  

Current Professional Liability Coverage

Current Insurance Carrier:

Limits of Liability:

$ per claim

 $ per aggregate

Effective Date:

    Claims Made

Retro Date:

    Occurrence

Physician/Surgeon Information

Specialty:

Board Certified:

Yes    No

Major Surgery    Minor Surgery    No Surgery

Claims History

Have any claims ever been made against you?

Yes   No

If yes, please complete the following claims supplement information sheet, or email us a loss run from your previous carriers.

Additional Comments

Please give any additional comments you feel appropriate for this premium indicator. If you have additional information where there was not enough space, please enter them here.