ProAssurance

Frequently Downloaded Forms

Visitors seeking healthcare professional liability insurance applications can find them on the new business applications page or the renewal applications page. If you have a suggestion for a form to be added to this page, please email AskMarketing@ProAssurance.com.

Affidavit of Retirement and/or Cessation of the Practice of Medicine Form

In the event of an insured professional’s full retirement, ProAssurance companies provide tail coverage at no additional premium charge—if the insured had continuous coverage with a ProAssurance company during the previous five years. For details, refer to Section VI. The Reporting Endorsement Provision is applicable to Insured Professionals of the Professional Liability Coverage Part of your policy.

After completing the Affidavit of Retirement form, please return it by fax (205.802.4710) or email (Information@ProAssurance.com). Your agent or underwriter can answer any further questions.

Download an Affidavit of Retirement and/or Cessation of the Practice of Medicine form.

Agent Document Delivery Preferences

Agents can confirm their delivery preferences for receiving printed policy documents and invoices, or opt to obtain documents electronically in the ProAssurance secure services portal.

After completing this form, please email it to CentralPrint@ProAssurance.com.

Download the Agent Document Delivery Preferences form.

Authorization and Release Form for Proof of Coverage and Claim History

A ProAssurance insured (or group policy representative) may use this form to authorize release of proof of coverage and/or claims history information to a third party, such as a hospital or credentialing service.

Once completed and signed, please return the form by fax or email to your ProAssurance customer service representative. The form may also be emailed to Credentialing@ProAssurance.com.

Download a Proof of Coverage and Claim History Authorization and Release form.

Business Associate Agreement and Health Information Privacy Statement

The ProAssurance Companies, along with our legal counsel, have reviewed the Health Insurance Portability And Accountability Act of 1996, and its implementing regulations (collectively, “HIPAA”). After our review, we have concluded that HIPAA Business Associate Agreements are not required in connection with our provision of medical professional liability insurance to our healthcare provider clients. While ProAssurance does receive Protected Health Information from its healthcare provider clients for the purpose of obtaining or maintaining medical liability coverage or obtaining the benefits from such insurance, such disclosures are allowed under HIPAA, without a Business Associate Agreement.

Download the full Business Associate Agreement and Health Information Privacy Statement.

Claim History or Loss Run Request Form

This is a confidentiality agreement, authorization, and release form for professional liability insurance customers requesting loss runs or claims history reports.

In most instances, the authorization form may be signed by the insured, a group policy authorized representative, or the agent of record for the respective policy/account information.

Email the completed and signed form to Credentialing@ProAssurance.com. Follow-up questions or issues may be sent to this email address as well.

Download a Confidentiality Agreement, Authorization, and Release Form for Claim History or Loss Run.

Electronic Payment Plan (EPP) Enrollment Form

Professional liability insurance policyholders can enroll to have payments automatically debited from their checking or savings accounts.

Use this form if you wish to enroll by mail or fax; the mailing address and fax number are listed on the form itself. You can also sign in to the Secure Services Portal to enroll online.

If you have questions, please call 800.282.6242 and ask to speak with a policy specialist.

Download the EPP Enrollment form.

Locum Tenens Coverage Request Form

A ProAssurance insured or agent can request a Certificate of Insurance for locum tenens coverage—a temporary substitute physician who will serve in the capacity of the insured, in their absence for vacation, illness, or other purposes. The coverage provided to an insured will also cover one or more properly licensed individuals who serve in your place as a temporary substitute. 

After completing the Locum Tenens Coverage Request form, please return it by fax (702.697.6422), or email (UWSCBham@ProAssurance.com). Your agent or underwriter can answer any further questions.

Download a Locum Tenens Coverage Request form.