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Application

It's easy to apply for coverage that's hard to beat.

We strive to make the application process as simple as possible. Step 1 is required for all new applicants. Follow the prompts to determine if you need to complete steps 2-4.

If you're adding ancillary personnel to an existing policy, skip to step 5. If you're adding locum tenens, skip to step 7. If you're applying for health care facility coverage, skip to step 8.

If you have any questions, please call 800.748.4380, and we will be happy to assist you.

  1. Step

    Individual Application

    Please fill out this brief application. Don't worry if it seems short, that's intentional.

    Download

  2. Step

    Prior Acts Coverage Form

    Covers you for claims that may arise from medicine practiced before the date of your UMIA policy. You'll need this if you didn't purchase Tail Coverage from your previous insurer. Please call if you have questions.

    Download

  3. Step

    Additional Named Insured Corporation

    This option extends your individual coverage to your corporation and is available at no additional charge. If you have a corporation, you should complete this form. However, depending on your situation, it might not be the best option. Please contact a UMIA underwriter if you have any questions.

    Download

  4. Step

    Independent Corporation

    This option sets up a second policy exclusively for your corporation in addition to your individual policy. If you have questions, call us, and we can help you determine the best option for your practice.

    Download

  5. Step

    Additional Named Insured Ancillary Personnel

    Fill out a separate form for each additional named insured. This includes physician assistants, certified registered nurse anesthetists, certified registered nurse midwives, certified registered nurse practitioners and perfusionists. Staff, including RNs and MAs, do not need to be added.

    Download

  6. Step

    Individual Ancillary Personnel

    Complete this application to set up an individual policy for a physician assistant, certified registered nurse anesthetist, certified registered nurse midwife, certified registered nurse practitioner or a perfusionist. These individuals must work exclusively with a UMIA-insured physician(s) or surgeon(s).

    Download

  7. Step

    Locum Tenens

    Add a locum tenens to your policy.

    Download

  8. Step

    Health Care Facilities

    Apply for hostpitals, long-term care and outpatient facilities.

    View applications

  9. Step

    Send Forms

    Scan the forms and send them via mail, email, or fax.

Mail

310 East 4500 South, Suite 550
Salt Lake City, Utah 84107-3993

Email

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You will need to scan the forms yourself and attach them to an email.

Fax

801.531.0381

Attn: UMIA Underwriting