Insurance Applications
Please use the following forms to apply for professional liability insurance coverage. After completing the application, save the document, print it and fax or mail to:

Midwest Medical Insurance Company
Attn: Sales and Marketing Department
7650 Edinborough Way, Suite 400
Minneapolis, MN 55435
Fax: 952-838-6808
 

Physician and Clinic Applications

• Certified Electronic Medical Record Risk Management Premium Credit Application
• Renewal Application for Physicians and Surgeons Professional Liability Claims-made
• Individual Physician Professional Liability Insurance Application
• Corporate Healthcare Professional Liability Insurance Application
• Prior Claim/Suit Information Addendum
• Emergency Medicine Physician Questionnaire
• Bariatric Surgery Questionnaire--Physicians & Surgeons
• Medical Directorship Questionnaire

Hospitals and Health Systems Applications

• Healthcare System Liability Protection Application
• Bariatric Surgery Questionnaire--Hospitals
• Policyholder Disclosure Notice of Terrorism Insurance Coverage

Other Applications

• Ancillary Professional Liability Insurance Application
• Healthcare Facilities Application

Add a New Physician to an Existing Policy

• Application for Physicians & Surgeons Professional Liability Insurance
• Prior Claim/Suit Information Addendum

Change Requests

• Physician Classification 
• Change Limits
• Organization Name and Address
• Physician/Ancillary Provider Name
• Cancel Physician/Ancillary Provider from Existing Policy
• Reporting Endorsement Quotation

An MMIC representative will contact you as soon as possible to complete the application process. If you have any questions regarding these forms, please contact the Sales and Marketing Department at (800) 328-5532. MMIC's business hours are Monday through Friday, 8 a.m. to 4:30 p.m. Central Standard Time.