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Inquiry Page
for Hospitals in California

Please fax or mail the completed application to us, attention Medical Malpractice Department. You will receive a quote within 24-48 hours, excluding weekends.

Fax:  310.453.7971
Address:   P.O. Box 511
  Santa Monica, CA 90406

*This form is in "pdf" format and requires Adobe's Acrobat Reader in order to be read and printed. If you do not already have Acrobat Reader installed on your computer, please click on the Acrobat image to the right to download a free copy.

Hospital Application

**Indications are estimates only and are based on the limited information provided. Any indication you receive from us in no way implies approval of coverage. Insurance carrier underwriting departments may require additional information and documents in order to provide an offer and bind coverage. They may require a completed application and questionnaire, a current declaration page and a company verified loss letter prior to approval.

Please make a
selection here

Phone 800.775.8642




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