AMPI - Medical Professional Liability Insurance

Malpractice Insurance for medical students

Your information

Please enter your name as it appears in the passport. All fields are required. Incomplete applications may experience processing delays.

First Name

Middle Name

Last Name

Date of birth

Email address

Permanent home address

Street

City

State

Country

ZIP code/PIN code

Medical school you are currently attending

Expected medical school 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 address

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?

Yes No

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

Will you be assisting in any obstetrical procedures?

Yes No

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

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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 for which you are applying 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. State insurance insolvency guaranty funds are not available for your risk retention group.

Coverage is limited to activities and locations listed on the application for enrollment.