Medical Sales Advocates

What We Do

CONTACT US:

Medical Sales Advocates

Toll-Free: 1-877-303-2050

Fax: 1-719-358-5113

General Inquires:
info@medicalsalesadvocates.com

Medical Sales Advocates Application

To receive immediate membership benefits, including insurance coverage, complete the form below.

Legal Company Name

Applicant Name

Contact Email

Phone Number

Website address

State of Incorporation

Year of Incorporation

Business Address Line 1

Business Address Line 2

City

State

Zip

How did you find us

Mailing Address (if different from business address)

Mailing Address Line 1

Mailing Address Line 2

Mailing City

Mailing State

Mailing Zip

Please don't also count owners as sales reps or w2 employees.

If you are an owner, do not also count yourself as a W-2 employee, i.e. do not double count

How many owners in the company?

How many w-2 administrative employees do you have?

How many 1099 sales reps do you have?

How many w-2 sales reps do you have?

Please note that the insurance benefit that comes with membership only provides coverage for acts relating to the profession of Medical device/product Sales and Distribution. If you perform another type of medical related service or business function, such as certification or refurbishing of equipment, or any function other than the device sales, please call 1-877-303-2050 for quotes on appropriate liability insurance protection.

Is your business limited to the sale and distribution of medical devices and/or products? If no, please provide a detailed explanation of the non-sales related business operations and their % of total revenue.

Yes No

This program is only for distribution organizations.

Please call 1-877-303-2050 to obtain a quote for manufacturing companies.

Is your business a Manufacturer of such devices and/or products?

Yes No

Please list the devices and/or products you sell.

Product Type	Product Name	Manufacturer

Risk Management

Do you have a written contract with all of the manufacturers you represent?

Yes No

Are you indemnified and / or insured by the manufacturer(s) of the devices you sell for product liability?

Yes No

Do you obtain annual certificates of insurance documenting your additional insured status on the manufacturer(s) products liability policy?

Yes No

Are you selling products outside the US Posessions and Canada?

Yes No

Please describe the training requirements for the products you represent and how often the training is required.

Can you actively keep records for all the products you represent, when the product was manufactured and to whom it was sold and when?

Yes No

Do you re-label or alter in any way the products you sell? Please provide details.

Yes No

If you answer answer yes to any of these questions, these products are excluded. Please call 1-877-303-2050 for eligibility.

Do you have a procedure in place for recalled products?

Yes No

Have any claims ever been made against the applicant or any person proposed for this insurance? If yes, please provide details

Yes No

Are you aware of any incidents which may result in a claim against you? If yes, please provide details.

Yes No

THE UNDERSIGNED DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. IT IS AGREED THAT THIS APPLICATION SHALL BE PART OF THE BASIS OF THE CONTRACT SHOULD COVERAGE BE AFFORDED AND THE APPLICATION WILL BE ATTACHED TO AND BECOME PART OF THE POLICY.

I attest to the above statements are true and accurate

I Accept The Terms & Conditions and understand that premium is earned 100% at inception

Please select the certificate you will need to credential:

Sec3ure (a service offered by IntelliCentrics, Inc)

Symplr (VCS)

Vendormate Inc.

HealthTrust Workforce Solutions

Green Security

Other (please provide name and address)