Application

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.

Step

INDIVIDUAL APPLICATION

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

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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.

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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.

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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.

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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.

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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).

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Step

LOCUM TENENS

Add a locum tenens to your policy.

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Step

HEALTH CARE FACILITIES

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

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Step

SEND FORMS

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


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


application@umia.com

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

801.531.0381

Attn: UMIA Underwriting