Applications and Forms

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

MMIC Group
Attn: Sales and Marketing Department
7701 France Avenue South, Suite 500
Minneapolis, MN 55435
Tel: (952) 838-6700
Fax: (952) 838-6808

Download Most Updated Version of Adobe Reader
The most recent version of Adobe Reader is required to complete /pdf applications.  Download the most up-to-date version at:  http://get.adobe.com/reader/     Click on the YELLOW download button. 

Physician and Clinic Applications

• Bariatric Surgery Questionnaire - Physicians and Surgeons
• Certified Electronic Medical Record Risk Management Premium Credit Application
• Corporate Healthcare Professional Liability Application
• Emergency Medicine Physician Questionnaire
• Medical Directorship Questionnaire
• Physicians And Surgeons Professional Liability Application - New Business
• Physicians And Surgeons Professional Liability Application - Renewal
• Prior Claim/Suit Information Addendum
• Vaginal Birth After Cesarean Questionnaire

Add a New Physician to an Existing Policy

• Physicians And Surgeons Professional Liability Application - New Business

Hospitals and Health Systems Applications

• Wisconsin UM/UIM Supplement
• Healthcare System Liability Protection Application - New Business
• Healthcare System Liability Protection Application - Renewal
• Policyholder Disclosure Notice of Terrorism Insurance Coverage

Healthcare Facilities

• Healthcare Facility General Application for Liability Insurance
• Behavioral Health Supplemental Application
• Home Health/Hospice/Medical Registry Supplemental Application
• Long-Term Care Supplemental Application
• Non-Direct Health Care Services Supplemental Application
• Rehabilitation Supplemental Application
• Schools for Health Care Professionals Supplemental Application
• Surgical/Specialized Services Supplemental Application
• Treatment Centers Supplemental Application
• Healthcare Facility Liability Protection Renewal Application
• Healthcare Umbrella Liability Application
• Wisconsin UM/UIM Supplement

Ancillary Providers

• Ancillary Professional Liability Application - New Business
• Ancillary Professional Liability Application - Renewal

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.

Download Most Updated Version of Adobe Reader
The most recent version of Adobe Reader is required to complete /pdf applications.  Download the most up-to-date version at:  http://get.adobe.com/reader/     Click on the YELLOW download button. 

Change Setting Preference to Adobe Reader
If the application is automatically opened in FOXIT, the properties of the document will need to be changed to Adobe.  Save the document and close it.  Then, locate the document and right click on it (prior to opening).  Click on “Properties”.  Under the “General” tab, change the “Type of File” to Adobe Reader and click Okay.  If you use Foxit, you will need to change properties back after completing the Adobe application.

Electronic Signature

• Click on the “Applicant Signature” tab at the end of the application.  Adobe will automatically take you through the steps necessary to create an electronic signature. 
• Click on the button that will allow you to create a digital ID (unless you already have one).
• There are two options creating the signature.  Chose the option:  New PKCS #12 digital ID file
• When an electronic signature is added at the end, the document will be automatically saved.  If you have already saved the documented, you can replace existing document or save as a new document.