Chiropractic Benefit Services

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Quick Quote

Want to know what the premiums will be on your CBS RPG policy? Fill out this "Quick Quote" form and we'll let you know. Then you can see for yourself how competitively priced really GREAT coverage can be!

Part 1: Contact information

Name:
Phone:
Secondary phone:
Fax:
Email:
Address:
City - State - Zip:

I do not currently receive The Chiropractic Journal but would like to receive a FREE subscription sent to the above address.

Part 2: General background information

Month/year you started practicing chiropractic:

School graduated from:

Part 3: Current Insurance Information

Current Malpractice Carrier:
Renewal Date:	/ / (mm/dd/yyyy)
Type of Policy (select one):	Claims-Made Occurrence No Insurance
Policy Limits:
Current Premium:
Retroactive Date (if claims-made policy):	/ / (mm/dd/yyyy)

Part 4: Claims history

Have you had either a malpractice claim or a professional board dispute filed against you? Yes No

Part 5: Practice information

State you practice in:

County you practice in:

Are you Full Time or Part Time (20 hours or less office time)?

Are there any MD's in your office? Check if yes.

Which adjuncts do you utilize in your office? Check all that apply.

Adjustments	Acupuncture	Nutrition	Ultrasound
Obstetrics	Electric Muscle Stimulation	Homeopathy	Hair Analysis
Vitamin Injections	Iridology	Interpretation of diagnostic blood, urine studies	Urinalysis
MRI/CT	EKG	Colon Irrigation
Other

Do you diagnose or treat medical symptoms such as heart disease, cancer, diabetes, epilepsy, multiple sclerosis, etc.? Yes No

Do you have written patient safety policies and practice standards?
Yes No

Do you utilize a written Informed Consent?
Yes No

Have you attended a Risk Management Seminar or Loss Control Workshop within the last year?
Yes No

Who is your practice management coach?

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