Download an application as an Adobe PDF file that you can complete and return.
Please refer to our Completion and Delivery Instructions prior to opening any of the applications on this page.
Physicians and Surgeons:
- Application for Physicians and Surgeons Professional Liability Insurance
- Application for Legal Defense Costs Coverage
- Supplemental Application for Bariatric Surgeons
- Supplemental Application for Part Time Practice
- Policy Administrator Designation and/or Change Form
- Application for Excess Professional Liability Insurance
Physicians/Surgeons Professional Entity:
Physician Assistants, Specialist Assistants, Nurse Practitioners, Midwives and Nurse Anesthetists:
Other Health Care Providers:
There are 3 easy ways to apply for MLMIC dental professional liability coverage.
Start or complete an application at the MLMIC Insurance Company rapid application portal.
- Mail (or Email/Fax)
- Download the Application for Dentists Professional Liability Insurance and return the completed application to MLMIC.
- Follow the Completion and Delivery Instructions for details on submitting your application.
- Part time practitioners must also submit a Supplemental Application for Part Time Practice.
Need help? Give us a call at 800-ASK-MLMIC (800-275-6564).
Hospitals and Groups:
Contact a MLMIC representative today.