Apply for Coverage

Apply for a new ISMIE Mutual policy:

The Individual Physician application, Partnership/Corporation/Clinic application, and Non-Physician Professional application for certain states are available in PDF format.

To access these applications, choose a state from the interactive map.

*Some states have editable PDF applications available for use. You may have problems saving and submitting the application if the PDF is completed in the browser window. Please download the editable application to your computer’s drive and then open and complete the application in Adobe. 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.

How to complete and submit an application

Complete all sections of the application, sign and save the document, and return it via your preferred method of submission.

1. Secure Method: Submit the application via the Submit to ISMIE form.
    
2. Email: underwriting@ismie.com
   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.
    
3. Mail: ATTN: Underwriting Division ISMIE Mutual Insurance Company, 20 N. Michigan Avenue, Suite 700, Chicago, IL 60602
    
4. Fax: (312) 782-2023

Applications and change forms can be found by selecting a link below:

Locum Tenens Coverage Application: Policy application for an existing policyholder to add a temporary physician to fill in while away from practice (e.g. maternity leave, extended travel).

Ancillary Employee Application: Policy application for allied healthcare professionals seeking new coverage when joining an existing ISMIE policy. Allied healthcare professionals included: registered nurses, technicians, medical assistants, and physical therapists.

Surgicenter Application: Policy application for ambulatory surgery center coverage.

Part-time Rating Application: Application for existing policyholders seeking part-time coverage.

Make changes to a policy:

Clinic/Corporation Application for Risk Manager Premium Discount: For clinics/corporations who employ a dedicated risk management professional (only available to a clinic policyholder).

Change Request Form: Change policy information (e.g. update limits; add a hospital; change mailing or billing address; add employees).

Practice Location Form: Add a new practice location.

Request a Quote Online Form | PDF  

Cancellation Request: existing policyholder cancellation form.