Forms and Applications

Apply for medical liability insurance coverage with ISMIE Mutual today. Questions? Please contact us by email at underwriting@ismie.com or at 800-782-4767.


Manage your ISMIE.com account:

Username and Password Request Form: create an account, retrieve login information or reset a password (not applicable to brokers).


Apply for a new policy or add someone to an existing policy:

Physician Application: policy application for physicians seeking new coverage, or for existing policyholders seeking to add a physician(s) to an ISMIE policy (MDs and DOs only).

Locum Tenens Coverage Application: policy application for an existing policyholder to add a temporary physician to fill in while away from practice (e.g. maternity leave, extended travel).

Ancillary Employee Application: policy application for allied healthcare professionals seeking new coverage when joining an existing ISMIE policy. Allied healthcare professionals included: registered nurses, technicians, medical assistants, and physical therapists.

Non-Physician Professional Application: policy application for non-physician professionals seeking coverage, or for existing policyholders seeking to add a non-physician professional to an existing ISMIE policy. Non-physician professional examples: physician assistants, nurse practitioners, certified registered nurse anesthetists, midwives, chiropractors, and podiatrists.

Corporation or Clinic Application: policy application for healthcare corporations or clinics. Common for: physician groups, independent physician groups, private practices, MRI centers, urgent/immediate care centers, and mental health clinics.

Surgicenter Application: policy application for ambulatory surgery center coverage.

Part-time Rating Application: application for existing policyholders seeking part-time coverage.

 

Make changes to a policy:

Clinic/Corporation Application for Risk Manager Premium Discount: for clinics/corporations who employ a dedicated risk management professional (only available to a clinic policyholder).

Change Request Form: change policy information (e.g. update limits; add a hospital; change mailing or billing address; add employees).

Practice Location Form: add a new practice location.

Qwik Quote: quote request form.

Cancellation Request: existing policyholder cancellation form.

 

Osteopathic Association Affinity Programs:

Pennsylvania

Pennsylvania Osteopathic Medical Association (POMA) (online form): online request for quote for members of the Pennsylvania Osteopathic Medical Association.

Pennsylvania Osteopathic Medical Association (POMA) (pdf): request for quote for members of the Pennsylvania Osteopathic Medical Association.

Indiana

Indiana Osteopathic Association (IOA) (online form): online request for quote for members of the Indiana Osteopathic Association.

Indiana Osteopathic Association (IOA) (pdf): request for quote for members of the Indiana Osteopathic Association.

Ohio

Ohio Osteopathic Association (OOA) (online form): online request for quote for members of the Ohio Osteopathic Association.

Ohio Osteopathic Association (OOA) (pdf): request for quote for members of the Ohio Osteopathic Association.

Iowa

Iowa Osteopathic Medical Association (IOMA) (online form): online request for quote for members of the Iowa Osteopathic Medical Association.

Iowa Osteopathic Medical Association (IOMA) (pdf): request for quote for members of the Iowa Osteopathic Medical Association.