Medical Professional Liability Insurance for Medical Students

Malpractice Insurance for Medical Students

Your information

First name *

Last name *

Date of birth *

Email *

Permanent home address
Street *

City *

State *

Country *

ZIP code/PIN code *

Medical school you are currently attending *

Expected graduation date *

Elective information

Rotation start date *

Rotation end date *

Institution where your elective will take place *

Institution address
Street *

City *

State *

Country *

ZIP code/PIN code *

Elective coordinator name *

Elective coordinator email *

Department supervising your clinical activities (Ex: Internal Medicine, Surgery, Pediatrics) *

Course description of all clinical activities you will be performing *

Will you be assisting in any surgical procedures? *
YesNo

If yes, list all procedures. If no, enter "N/A"

Will you be assisting in any obstetrical procedures? *
YesNo

If yes, list all procedures. If no, enter "N/A"

Additional information

Are you a member of an association? *

What is your membership number?

How did you hear about the AMPI Medical Malpractice Insurance Program? *

Type your signature *

Date *

Note to Applicants: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any material fact hereto, commits a fraudulent insurance act, which is a crime and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your State. Insurance insolvency guaranty funds are not available for your risk retention group.