Application/Renewal

Please complete the initial brief application and submit. We can email, fax, or mail you a full application once your License is verified or you can print an application form below.
If you have questions or concerns please call us directly at (904) 854-6056

* Indicates required field

Policyholder Name *

First

Last

Policy Number *

License Number *

Policy Type *

Phone Number *

Contact Name *

First

Last

Title *

Policyholder Office Manger/ Administrator Other

Contact Email *

Contact Phone Number *

Contact Fax Number *

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Please provide name and coverages of Professional Liability Coverage Information below : *

Please provide current hospital affiliations *

Payment Method *

Online Payment (go to pay online page) Credit Card By Phone (904-854-6056) Mailing Check Today

Submit

*By submitting you are giving permission for FPA/FPALDIC to contact you by email.

Physicians application can be printed and mailed, faxed, or emailed!
Email to: george.brew@fpalegaldefense.com, fax to: 904-854-6057