How to Apply

Application for New Business Physicians & Surgeons

Thank you for your interest in applying for Professional Liability Coverage from Millennium Insurance Company. The application is several pages long and certain specific information will be required. Before beginning, please make sure you have the following items available: Social Security Number Tax ID Number Prior Carrier Information Claims Information Medical License Numbers DEA License Number Additional requirements for new business physicians & surgeons include: Current declarations page Current CV Copy of your medical license Prior carrier loss runs (10 years) Copy of Practice Letterhead By downloading a digital file of the application, you agree that you understand that the completion of this application and subsequent submission of this application does not guarantee coverage or that coverage will be offered. Click here to download the Medical Practitioners Application. You will need to have Adobe Acrobat Reader (version 4 or better) to view PDF. Click here if you do not have this program installed yet.