Professional Liability Insurance Application
Physicians who desire to apply for professional liability insurance from Michigan Professional Insurance Exchange (MPIE) are required to fully complete, sign, and date the application along with submitting the following information.
In addition to the Application for Insurance, please enclose a copy of the following:
- Renewal certificate/current Insurance policy declaration page which shows your retroactive date.
- Loss runs from all prior insurance companies or explanation as to why they are not available.
- Copy of curriculum vitae.
Once complete, please submit all documents using one of the following methods:
Fax: (616) 741-1980
Mail: Michigan Professional Insurance Exchange
Attn: Underwriting Department
333 Bridge St NW
Grand Rapids, Michigan 49504
The information you provide is confidential and will not be reviewed by anyone other than the Exchange and its counsel and other advisers, unless a review is required by a governmental agency.