First, we need to collect some information about you and your practice. You’ll need to complete and submit this form. After your information is reviewed, one of our underwriters will contact you to discuss your options, answer any of your questions, and provide you with a quote.
In addition to completing the Insurance Application, you will also need to provide the following documentation:
- Renewal certificate/current Insurance policy declaration page which shows your retroactive date.
- Loss runs from all prior insurance companies or explanation as to why they are not available.
- A copy of curriculum vitae.
You may fax or deliver your completed Insurance Application to:
Fax: (616) 741-1980
Michigan Professional Insurance Exchange
Attn: Underwriting Department
333 Bridge St NW
Grand Rapids, Michigan 49504
Have questions? See our most commonly asked underwriting questions.