apply - COVID Volunteer

Application - Coverage for Medical Services Provided on a

Voluntary Basis During the COVID-19 Pandemic


As part of MLMIC's ongoing efforts to support and accommodate the medical community as it battles COVID-19, any physician who was last insured by MLMIC prior to their retirement, will have access to professional liability coverage, without requiring any new premium, if they return to volunteer and aide in the COVID-19 efforts.  The same policy benefits and coverages will be provided as when the volunteering physician was actively practicing medicine and insured with MLMIC.

The premium is waived and your decision to return to practice as a volunteer will have no impact on any previously issued extended reporting period, or tail coverage with us.

Please complete the fields below.  Once we receive your request, we will return evidence of insurance to you via email.  If we need additional information, we will contact you as quickly as possible.  If you have any questions, please call us at 800-ASK-MLMIC.

 
Name
First Name *
Middle Name
Last Name *
 


 
Practice Information
License Number *
SSN (last four digits) *
Former Policy Number
 


 
Current Contact Information
Mailing Address *
City *
State *
Zipcode *
Email Address *
Phone Number *
 


 
Acknowledgement
I certify that I was formerly insured by MLMIC before retiring from the practice of medicine. I will be furnishing limited medical services on a voluntary, pro bono basis during the COVID-19 pandemic in accordance with the medical professional practice allowances and limitations contained in all federal and state Acts, Orders and Declarations applicable to the pandemic. I understand that no insurance is provided for any professional services for which I am compensated by any source (other than the reimbursement of actual expenses).

New York State Insurance Regulation Declares That:
"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 fact materially thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation".
By selecting yes I confirm that I have reviewed and attest to the accuracy of the information provided. I also confirm that I am the insured. *
Yes
By entering my initials below, I understand and agree that by clicking the "submit" button, (i) I am electronically signing this application, (ii) that I have reviewed the contents of the application in its entirety and understand and accept the terms therein (iii) my statements in the application are to the best of my knowledge and belief, true, correct and complete and (iv) I intend this application to be a legally binding obligation as if I had affixed my signature to the application by hand.
Applicant Initials *