Medical Sales Advocates

What We Do

CONTACT US:

Toll-Free: 1-877-303-2050

Fax: 1-719-358-5113

General Inquires:
info@medicalsalesadvocates.com

If you are not a Medical Device Sales Representative or Distributor and therefore not covered by the Medical Sales Advocates group insurance plan, please complete the following form and a representative will contact you to discuss your current insurance concerns.

Name

First Name Last Name

Company Name

Number of Employees

Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website Address (type none if needed)

Email Address

Phone Number

Your Profession and related duties

Please give as much detail as possible

Requested Policy Effective Date

Desired Coverage(s)

Professional Liability
General Liability
Product Liability
Completed Opperations
Workers Compensation

please click all that apply

Please list any other desired insurance product

Desired Professional Liability Limits

please include your desired per occurrence and aggregate limits

Desired General Liability Limits

please include your desired per occurrence and aggregate limits

Historical (past 5 yrs.) Annual Revenues

Please include the year and the corresponding revenue for each given year for the past 5 years. Type "none" if you are a new business. If your business has not reached it's 5th year anniversary, please include revenue for all years incorporated.

Applicant Type

Corporation
Partnership
Sole Proprietor
Other

please choose one

Do you sell/lease durable medical equipment

If so, please list your total annual sales/rental receipts

Any claims in the last 7 years

If so, please give as much detail as possible regarding the policy and insurance carrier that handled the claim (if any), claim outcome, etc.