Start Your Professional Liability Quote

Please use the form below to submit the basic information requested for our team to start your insurance quote. Once the form is complete, attach a copy of your DECLARATIONS Page (your current policy cover sheet) using the file upload button at the end of the form. We will follow up with a phone call within 24 business hours to discuss your policy options and gather further information.

If you prefer, you can print the form and fax the form to 248-889-9499 with the
subject of ‘New Insurance Quote’.

Print Form

First Name, Middle Initial*
Last Name*
Degree*
Specialty*
Business Name*
Primary Business Address*
City*
State*
Zip Code*
County*
Hours worked per week*
INSURANCE INFORMATION
Please also attach Current DECLARATIONS Page
Current Insurance Company*
Policy Period From:*
To:*
- Occurence
- Claims Made
- Claims-Made w/ Pre-Paid Tail
Limits $*
Annual Premium $*
Do you anticipate practicing for at least five more years?*
- Yes
- No
Loss Information
Have there been any claims resulting in settlements in the past 10 years?*
- Yes
- No
Please upload your DECLARATIONS Page here:

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Start Your Professional Liability Quote

INSURANCE INFORMATION

Loss Information

Phone: (248) 889-8578 | Email: Dean@sisagency.com 840 Lone Tree Road Milford MI 48380

Phone: (248) 889-8578 | Email: Dean@sisagency.com
840 Lone Tree Road Milford MI 48380