Apply for Coverage with MICA

Please select your product type and the state where you require coverage.


View a specimen MPL policy form

Arizona

Individual Physician - Arizona
Physician Submission Checklist

Application for Reporting Policy

Prior Acts Application, if applying for prior acts coverage

Payment Plan Selection Form

e-Med Protection Application for Higher Limits

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

General Surgery - AZ, CO, NV, UT

Gynecology - AZ

Hand Surgery - AZ, CO, NV, UT

Hospitalist - AZ, CO, NV, UT

Obstetrics - AZ, CO, NV, UT

Ophthalmology - AZ

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

Orthopedics - AZ

Otorhinolaryngology - AZ

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


Business Enterprise (Group) - Arizona
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

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


Nurse Practitioner - Arizona Medical Facility - Arizona


Colorado

Individual Physician - Colorado
Physician Submission Checklist

Application for Reporting Policy

Prior Acts Application, if applying for prior acts coverage

Payment Plan Selection Form

e-Med Protection Application for Higher Limits

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

General Surgery - AZ, CO, NV, UT

Gynecology - CO, NV, UT

Hand Surgery - AZ, CO, NV, UT

Hospitalist - AZ, CO, NV, UT

Obstetrics - AZ, CO, NV, UT

Ophthalmology - CO, NV, UT

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

Orthopedics - CO, NV, UT

Otorhinolaryngology - CO, NV, UT

Pathology - AZ, CO, NV, UT

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


Business Enterprise (Group) - Colorado
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

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


Nurse Practitioner - Colorado Medical Facility - Colorado


Nevada

Individual Physician - Nevada
Physician Submission Checklist

Application for Reporting Policy

Prior Acts Application, if applying for prior acts coverage

Payment Plan Selection Form

e-Med Protection Application for Higher Limits

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

General Surgery - AZ, CO, NV, UT

Gynecology - CO, NV, UT

Hand Surgery - AZ, CO, NV, UT

Hospitalist - AZ, CO, NV, UT

Obstetrics - AZ, CO, NV, UT

Ophthalmology - CO, NV, UT

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

Orthopedics - CO, NV, UT

Otorhinolaryngology - CO, NV, UT

Pathology - AZ, CO, NV, UT

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


Business Enterprise (Group) - Nevada
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

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

Medical Facility - Nevada


Utah

Individual Physician - Utah
Physician Submission Checklist

Application for Reporting Policy

Prior Acts Application, if applying for prior acts coverage

Payment Plan Selection Form

e-Med Protection Application for Higher Limits

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 - UT

General Surgery - AZ, CO, NV, UT

Gynecology - CO, NV, UT

Hand Surgery - AZ, CO, NV, UT

Hospitalist - AZ, CO, NV, UT

Obstetrics - AZ, CO, NV, UT

Ophthalmology - CO, NV, UT

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

Orthopedics - CO, NV, UT

Otorhinolaryngology - CO, NV, UT

Pathology - AZ, CO, NV, UT

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


Business Enterprise (Group) - Utah
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

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


Nurse Practitioner - Utah Medical Facility - Utah