How to complete and submit application
Complete all sections of the application, sign and save the document, and return it via your preferred method of submission.
- Secure Method: Submit the application via the Submit to ISMIE form.
- Email: firstname.lastname@example.org
Please Note: This application contains Protected Information and email is not secure unless encrypted with password protection. By submitting the application by email, you acknowledge that email is not a secure method of communication and could potentially be viewed by unauthorized persons who might intercept or read those emails.
- Mail: ATTN: Underwriting Division ISMIE Mutual Insurance Company, 20 N. Michigan Avenue, Suite 700, Chicago, IL 60602
- Fax: (312) 782-2023
To have the application signed with an electronic signature, please use one of the approved software providers; Docusign, AdobeSign, EasySign, and RightSignature. To request approval for the use of an electronic signature software that is not listed here, please email email@example.com with the software name.
If you have questions or need assistance, please contact us at firstname.lastname@example.org or (800)-782-4767.
*Some states have editable PDF applications available for use. The application will automatically open in your internet browser. Please download or save the application to your computer, then open and complete in Adobe for submission. Adobe Acrobat Reader is required to access the applications. If you do not have Adobe Acrobat Reader installed on your system, please click here to install Adobe Acrobat Reader now.
Application for Individual Physician Professional Liability Insurance
Policy application for physicians seeking new coverage, or for existing policyholders seeking to add a physician(s) to an ISMIE policy (MDs and DOs only).
Application for Partnership/Corporation-or-Clinic Option for Professional Liability Insurance
Policy application for healthcare corporations or clinics. Common for: physician groups, independent physician groups, private practices, MRI centers, urgent/immediate care centers, and mental health clinics.
Application for Non-Physician Professional Liability Insurance
Policy application for non-physician professionals seeking coverage, or for existing policyholders seeking to add a non-physician professional to an existing ISMIE policy. Non-physician professional examples: physician assistants, nurse practitioners, certified registered nurse anesthetists, midwives, chiropractors, and podiatrists.