What Type of Coverage Are You Applying For?

What Type of Coverage Are You Applying For?

Individual Physician Application

Online Application

If you would like to use our online application, once you start the application, you'll be able to save it to finish later, and you'll receive an email with instructions on how 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

If you would like to use our online application, once you start the application, you'll be able to save it to finish later and you'll receive an email with instructions on how 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