Professional Liability Coverage Application

Our Individual Professional Liability policy may be applied for if you live in the following states:

AK, AL, AZ, AR, CA, CO, CT, DC, DE, GA, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MN, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR , PA, RI, SC, SD, TN,TX, UT, VA, VT, WA , WI, WV and WY.

Policies issued in Kentucky are subject to a county surtax "premium surcharge pursuant to KRS 136.392 for the purpose of funding the Firefighters Foundation Program fund and the Law Enforcement Foundation Program fund" which is not included in the gross premium stated but is billed upon policy issuance.

Pharmacist applicants applying in the first year following date of graduation from Pharmacy School qualify for a 50% discount.

First year Pharmacy Technician applicants qualify for a 40% discount (1st year premium of $45)

Individual Pharmacist Professional Liability policyholders under age 30 will be provided a $5,000 level term to age 30 life insurance policy through The Pharmacists Life Insurance Company, Algona, Iowa. The $5,000 term life insurance policy may be converted at various dates to a permanent life insurance plan for any amount up to $25,000 without evidence of insurability. The life insurance policy will expire if not converted within 30 days of the anniversary date following the policyholder's 30th birthday. See policy for details. Effective dates vary by state and not available in all states

Instructions for completing Individual Professional Liability Application form.

1.	Choose the correct description of your Pharmacist role from the following. The annual gross premium is given for each. Remember the classification or write it down to be used on the application form.

Pharmacy Technician
$75 (1 million per occurrence/3 million aggregate),
Individual who is a registered, licensed or certified pharmacy technician or has completed an approved pharmacy technician or qualifying continuing education program.

Employed Pharmacist
$144 (1 million per occurrence/3 million aggregate),
Individual who is a licensed and registered pharmacist. Includes an employee of a community pharmacy, chain pharmacy, hospital or other facility where they receive a W-2 at year end. Also includes pharmacy students who have completed their state boards and are licensed.

Owner, Partner, Corporate Officer WITH Pharmacists Mutual Business Insurance
$144 (1 million per occurrence/3 million aggregate),
Owners, Partners or Corporate Officers of a pharmacy or pharmacy related business that carries Pharmacists Mutual business insurance.

Independent Contractor, Consultant or Relief Pharmacist
$375 (1 million per occurrence/3 million aggregate),
Contact Pharmacists Mutual Insurance Company at 800-247-5930 or e-mail us at info@phmic.com concerning other important coverages you may need.

Pharmacy Student and Intern
$32 (1 million per occurrence/3 million aggregate),
A pharmacy student who has not yet completed the state boards and is not registered. This would include undergraduate students, interns and graduate students.

Instructor/Staff Pharmacist at Accredited College or Facility
$75 (1 million per occurrence/3 million aggregate),
A full time instructor/faculty member pharmacist at an accredited college or facility, who may on occasion engage in the practice of pharmacy.

2.	Complete all fields on the application form. Include at least one phone number either work or home. .

3.	Use the browsers back button to return to this screen and the forward button to return to the form. Use the back button to return back to the application form from the "success" message after submitting application. .

4.	Print the completed application for your records.

Warning: A person who knowingly submits an application or files a claim with intent to defraud against an insurer is guilty of a crime and may be subject to criminal and civil penalties.

Home Search Contact Us Pharmacy Links

808 Highway 18 West • P.O. Box 370 • Algona, Iowa 50511
800-247-5930 • Fax 515-295-9306