AMSA - Academic Group

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

Maria Lenti
maria.lenti@academicgroup.com
646-808-0602

AMSA APPLICATION FORM:

* Indicates required field

Name *

First

Last

Full Home Address *

Date of Birth (mm/dd/yyyy) *

Email *

Medical school you are currently attending *

Expected Graduation Date (mm/dd/yyyy) *

Department supervising clinical activities *

Full course description of all clinical activities. (You may copy and paste a course description.) *

Full name and address of location where elective will take place *

Will you be assisting in any surgical procedures? *

Yes No

If yes, please list the procedures *

Start of rotation date (mm/dd/yyyy) *

End of rotation date (mm/dd/yyyy) *

contact email of elective coordinator *

How did you hear about us? *

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

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.

Apply for Coverage

AMSA APPLICATION FORM:

COVERAGES

COMPANY

SUPPORT

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