Need to Make a Change to Your Policy?

We’ve got you. Use this secure form to submit your request and our team will take it from here.

"*" indicates required fields

Step 1 of 3

33%

Client Information

Name*

First Last

Email*

Phone

Insured Business Name*

Policy Number*

Request Type

What would you like help with today?

Update or change something on my current policy

Request a policy document

Report an incident or potential claim

Update business information

Other

Select all of the changes that apply:

Changing Location

Adding a NEW (additional) Location

Removing a Location

Adding a New Service/Procedure

Removing a Service/Procedure

Change Medical Director

Change in Ownership

Change in Employees

Effective Date of the Move*

MM slash DD slash YYYY

When did you move to a new location or add on this new location?

What's the address of the location you want to REMOVE?*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

What's the new address of your location?*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Will this move just be a new location to replace the old one, or a new location that will be added to existing policy?*

Replace the Existing Location

Add an Additional Location

What will you be doing new, that you’re not doing now, at your next location?*

Let us know anything else you think would be helpful in processing your request more efficiently.

Why are you removing this location/service/procedure?*

Do you expect an increase in your revenue?*

For example, what will your increase in revenue per month be?

Please list all new services/procedures/treatments you are requesting to add to you current policy:

New Service/Procedure/Treatment Offered:

Estimated procedure count for each service annually:

Please enter one service per line. (Click + to List Multiple Services)

Upload Required Documents*

Max. file size: 128 MB.

Upload any Training Certificates for those providing the services and Consent Forms for Patients

List all service(s) you won't be including on your next renewal*

Please enter one service per line. (Click + to List Multiple Services)

Medical Directors (supervising, collaborative) physicians are automatically covered per the Definition of Named Insured” in your policy. Only requirement is that they are licensed physician in your state.

New Medical Director*

Full Name and Title

If there's been a change in ownership, a new policy order may be required. Let's get some information first.

Full Name of New Owner*

Full Name and Title

If there's a change to your Business Name, please list it below.*

What is the reason for the change?*

Please provide us with some context surrounding this change.

All employees and contractors are automatically covered, per the “Definition of Named Insured” in your policy. When the new employee is being hired to add a new service, procedure or treatment this may affect your policy.

Are you removing or adding employees?*

Removing Employee

Adding Employee

Please list the employee(s) and their role that you are REMOVING:*

Employee Name

Role

Please enter one employee per line. (Click + To List Multiple Employees)

Please list the employee(s) and their role that you are ADDING:*

Employee Name

Role

Please enter one employee per line. (Click + To List Multiple Employees)

I have an active policy, and I would like to*

Full Name of Additional Insured*

Type it EXACTLY as you would like it to appear on the certificate.

Select Your Agent*

An incident has occurred, I need help with*

Select from the list below to learn more.

Upload Files

You may upload any files that will help us process this request.

Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 128 MB.

Is there anything else you would like to share with us to help process your request more efficiently?

"*" indicates required fields

Step 1 of 3

33%

Client Information

Name*

First Last

Email*

Phone

Insured Business Name*

Policy Number*

Request Type

What would you like help with today?

Update or change something on my current policy

Request a policy document

Report an incident or potential claim

Update business information

Other

Select all of the changes that apply:

Changing Location

Adding a NEW (additional) Location

Removing a Location

Adding a New Service/Procedure

Removing a Service/Procedure

Change Medical Director

Change in Ownership

Change in Employees

Effective Date of the Move*

MM slash DD slash YYYY

When did you move to a new location or add on this new location?

What's the address of the location you want to REMOVE?*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

What's the new address of your location?*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Will this move just be a new location to replace the old one, or a new location that will be added to existing policy?*

Replace the Existing Location

Add an Additional Location

What will you be doing new, that you’re not doing now, at your next location?*

Let us know anything else you think would be helpful in processing your request more efficiently.

Why are you removing this location/service/procedure?*

Do you expect an increase in your revenue?*

For example, what will your increase in revenue per month be?

Please list all new services/procedures/treatments you are requesting to add to you current policy:

New Service/Procedure/Treatment Offered:

Estimated procedure count for each service annually:

Please enter one service per line. (Click + to List Multiple Services)

Upload Required Documents*

Max. file size: 128 MB.

Upload any Training Certificates for those providing the services and Consent Forms for Patients

List all service(s) you won't be including on your next renewal*

Please enter one service per line. (Click + to List Multiple Services)

New Medical Director*

Full Name and Title

If there's been a change in ownership, a new policy order may be required. Let's get some information first.

Full Name of New Owner*

Full Name and Title

If there's a change to your Business Name, please list it below.*

What is the reason for the change?*

Please provide us with some context surrounding this change.

Are you removing or adding employees?*

Removing Employee

Adding Employee

Please list the employee(s) and their role that you are REMOVING:*

Employee Name

Role

Please enter one employee per line. (Click + To List Multiple Employees)

Please list the employee(s) and their role that you are ADDING:*

Employee Name

Role

Please enter one employee per line. (Click + To List Multiple Employees)

I have an active policy, and I would like to*

Full Name of Additional Insured*

Type it EXACTLY as you would like it to appear on the certificate.

Select Your Agent*

An incident has occurred, I need help with*

Select from the list below to learn more.

Upload Files

You may upload any files that will help us process this request.

Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 128 MB.

Is there anything else you would like to share with us to help process your request more efficiently?