Aniello Insurance Agency
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Aniello Insurance Agency
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Aniello Insurance Agency
3012 West Charleston Blvd.
Suite 150
Las Vegas, NV 89102
Phone: 702 259-0250
Fax: 702 259-0662
info@anielloinsurance.com

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Aniello Insurance Agency
Aniello Insurance Agency

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Medical Malpractice Premium Indicator

We would like to provide you with a free, no-obligation medical malpractice premium indicator. Please provide as much information possible for the most accurate premium. This information will be kept confidential and will be used for this purpose only.

General Information
Your Name:
Your E-Mail Address:
Primary Practice Address:
City: State:  Zip: 
Office Phone:   Office Fax:
Date of Birth:   # of Years in Private Practice:

 

Practice Information
Check each that applies to your practice
Individual
Group Practice
Partnership
Professional Corporation
Association
Affiliation
Other: 
 

 

 

Current Professional Liability Coverage
Current Insurance Carrier:
Limits of liability: $ per claim       $ aggregate
Effective Date:     Retroactive Date:
Premium: $

 

Physician/Surgeon Information
Specialty:
Practice Operates:
Board Certified
Full Time   Part Time
Yes   No

 

Claims History
This information is kept strictly confidential

Claim #1
  Claim Status: Closed   Open
Patient Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Dollar Amount: Paid on your behalf: $   Reserved on your behalf: $

Claim #2
  Claim Status: Closed   Open
Patient Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Dollar Amount: Paid on your behalf: $   Reserved on your behalf: $

Claim #3
  Claim Status: Closed   Open
Patient Name:   Date of occurrence:
Insurance Carrier:   Location of occurrence: 
Allegations:
Dollar Amount: Paid on your behalf: $   Reserved on your behalf: $

 

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.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   


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Aniello Insurance Agency

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Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.
Aniello Insurance Agency

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Aniello Insurance Agency