Welcome AMSA Members:

AMPI RRG, LLC can provide AMSA Members with medical professional liability insurance coverage for the specific period of time coverage is required. All that is required to get started is to complete the application below.

Once submitted your application will be reviewed and a response and quotation will be emailed back to you within 2 business days.

The insurance policy will be issued after receipt of all material including payment.

If you have any questions please contact

Peter Leone

peter@academicins.com

646-808-0581

Academic Medical Professionals Insurance Risk Retention Group, LLC Application for Membership and Insurance
Medical Professional Liability Insurance for (Visiting) Medical Students
First Name:
Last Name:
Home Address:
Date of Birth (mm/dd/yyyy):
Email Address (required)
Medical School Currently Attending:
Expected Graduation Date:
Name of medical school where elective will take place:
Department supervising clinical activities:
General description of clinical activities:
Address and Location of Institution where clinical activity will take place:
Start Date of Rotation (mm/dd/yyyy):
End Date of Rotation (mm/dd/yyyy):
Total Number of Days of Coverage Required:
Printed name / Signature:
Date (mm/dd/yyyy):
Type characters from picture:

Incomplete applications will not be considered.
Please be sure to submit a fully completed application.

Note to Applicants:  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 material fact hereto, commits a fraudulent insurance act, which is a crime and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.