Apply For Coverage

To start a new application or return to an online application, select the option below that best describes your coverage needs. If you have any questions about the application process, please call 800-681-1840.

**If you are a former MICA insured with online account credentials, log into our member portal to submit your online application.**

Application Options

Individual Physician Application

Online Application

To access a new online application or resume an application you already started, use the button below. You are able to save the online application to finish later, and will receive an email with instructions and a "resume code" to access your application.

  1. Online: Individual Physician Application

Downloadable Application

You can also use our downloadable PDF application to fill in or print, and once you have finished, either email it to micauw@mica-insurance.com or mail in.

MICA's Mailing Address: 2602 E Thomas Rd, Phoenix, AZ 85016.

  1. PDF: Full Individual Physician Application
  2. PDF: Short Form Application (AZ & UT ONLY) 

*The short form application should ONLY be used for a group submission along with a roster, loss runs, CVs, COI/Dec pages

Advanced Healthcare Professional Application

This application choice is for CNM, CRNA, NP or PA.

Online Application

To access a new online application or resume an application you already started, use the button below. You are able to save the online application to finish later, and will receive an email with instructions and a "resume code" to access your application.

  1. Online: AHP Application

Downloadable Application

You can also use our downloadable PDF application to fill-in or print, and once you have finished, either email it to micauw@mica-insurance.com or mail in.

MICA's Mailing Address: 2602 E Thomas Rd, Phoenix, AZ 85016.

  1. PDF: AHP Application

Business Entity (Group) Application

Downloadable Application

You can also use our downloadable PDF application to fill in or print, and once you have finished, either email it to micauw@mica-insurance.com or mail in.

MICA's Mailing Address: 2602 E Thomas Rd, Phoenix, AZ 85016.

  1. PDF: Business Entity (Group) Application

Facility Application

Downloadable Application

You can also use our downloadable PDF application to fill in or print, and once you have finished, either email it to micauw@mica-insurance.com or mail in.

MICA's Mailing Address: 2602 E Thomas Rd, Phoenix, AZ 85016.

  1. PDF: Facility Application

Additional Insured

Downloadable Application

If you employ healthcare professionals and would like to apply for coverage under your policy with shared limits.

You can also use our downloadable PDF application to fill in or print, and once you have finished, either email it to micauw@mica-insurance.com or mail in.

MICA's Mailing Address: 2602 E Thomas Rd, Phoenix, AZ 85016.

  1. PDF: Additional Insured Application