Physician Submission Checklist-What do I need to submit to apply for coverage?

Application for Reporting Policy

Prior Acts Application, if applying for prior acts coverage

Payment Plan Selection Form

e-Med Protection Application for Higher Limits

e-Med Protection Application for Higher Limits Effective 3-1-19

Claims Narrative Addendum

Authorization to Direct Premium Refunds


Supplemental Application, if you practice in any of the specialties listed below:

Anesthesiology - AZ, CO, NV, UT

Cardiology - AZ, CO, NV, UT

Cosmetic Surgery - AZ, CO NV, UT

Dermatology - AZ, CO, NV, UT

Family/General Medicine - AZ, CO, NV

Family/General Medicine - UT

General Surgery - AZ, CO, NV, UT

Gynecology - AZ

Gynecology - CO, NV, UT

Hand Surgery - AZ, CO, NV, UT

Hospitalist - AZ, CO, NV, UT

Obstetrics - AZ, CO, NV, UT

Ophthalmology - AZ

Ophthalmology - CO, NV, UT

Ophthalmology - Refractive Surgery - AZ, CO, NV, UT

Orthopedics - AZ

Orthopedics - CO, NV, UT

Otorhinolaryngology - AZ

Otorhinolaryngology - CO, NV, UT

Pathology - AZ, CO, NV, UT

Perinatology - AZ

Physical Medicine & Rehabilitation - AZ, CO, NV, UT

Plastic Surgery - AZ, CO, NV, UT

Radiology - AZ, CO, NV, UT

Urology - AZ, CO, NV, UT

Limited Medical Practice Application, if applying for part-time coverage:

Limited Practice Application

Additional Insured Application, if you employ any of the following extended role providers and would like to apply for coverage under your policy: Acupuncturist, Certified Registered Nurse Anesthetist, Dentist, Neonatal Nurse Practitioner, Nurse Midwife, Nurse Practitioner, Optometrist, Perfusionist, Physician Assistant, Psychologist, Surgical Assistant, Therapist (behavioral, occupational, physical or respiratory)

Additional Insured Application

 

Nevada Amendatory Endorsement

Underwriting Requirements for Advanced Healthcare Professional Applicants-What do I need to submit to apply for coverage?

Application for Reporting Policy-Advanced Healthcare Professional

Prior Acts Application-Advanced Healthcare Professional

Payment Plan Selection Form

e-Med Protection Application for Higher Limits

e-Med Protection Application for Higher Limits Effective 3-1-19

Claims Narrative Addendum

Authorization to Direct Premium Refunds

Nevada Amendatory Endorsement

Please note that in addition to the Group Applications listed below, each individual physician group member must complete an individual application to apply for coverage with MICA.

Underwriting Requirements for Business Enterprise (Group) Applicants

Business Enterprise New Business Application for Reporting Policy

Prior Acts Application, if applying for prior acts coverage

Payment Plan Selection Form

e-Med Protection Application for Higher Limits

e-Med Protection Application for Higher Limits Effective 3-1-19

Claims Narrative Addendum

Authorization to Direct Premium Refunds


Additional Insured Application, if you employ any of the following extended role providers and would like to apply for coverage under your policy: Acupuncturist, Certified Registered Nurse Anesthetist, Dentist, Neonatal Nurse Practitioner, Nurse Midwife, Nurse Practitioner, Optometrist, Perfusionist, Physician Assistant, Psychologist, Surgical Assistant, Therapist (behavioral, occupational, physical or respiratory)

Additional Insured Application

 

Nevada Amendatory Endorsement

Underwriting Requirements for Medical Facility Applicants

Application for Facility Professional Liability Insurance

Facility Roster

Prior Acts Application, if applying for prior acts coverage

Payment Plan Selection Form

e-Med Protection Application for Higher Limits

e-Med Protection Application for Higher Limits Effective 3-1-19

Claims Narrative Addendum

Authorization to Direct Premium Refunds

Nevada Amendatory Endorsement