AMPI Student Application Form

Coverage is available to students applying for clinical rotations in the United States and worldwide* who require medical student professional liability insurance coverage:

*Temporarily, The Academic Group will not be providing coverage to foreign medical students who are attending medical school outside the U.S., and are seeking coverage for an elective that is also outside the U.S. This is temporary as we finish the process of updating our medical student program. This message will be removed once we resume providing this service.

Academic can provide medical students with student professional liability (malpractice) insurance coverage for the specific period of time coverage is required.

A cost quotation and additional details will be sent out within 2 business days after a fully completed application is received.

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

Complete the following application, click on “send” and we will respond to your application by email.

Academic Medical Professionals Insurance Risk Retention Group, LLC Application for Membership and Insurance
Medical Professional Liability Insurance for (Visiting) Medical Students ( * - required )

AMPI APPLICATION FORM:

BEFORE YOU APPLY: If you are not a Medical Student or not currently enrolled in medical school, have graduated, or currently in your residency please contact Maria.Lenti@academicgroup.com to discuss your coverage options.

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

The policy for which you are applying is issued by a risk retention group. The risk retention group may not be subject to all of the insurance laws and regulations of your state of domicile. State insurance insolvency guaranty funds are not available for risk retention groups.”

* Indicates required field

First Name (as it appears on your passport) *

Last Name (as it appears on your passport) *

Permanent Home Address (including country and zip/pin code if applicable. This address should match the address as written on your application(s) to the institutions(s) to which you are applying)* *

Date of Birth (month/day/year | mm/dd/yyyy) *

Email *

Medical school you are currently attending *

Expected Graduation Date (mm/dd/yyyy) *

Department supervising clinical activities (Department that will be supervising your clinical activities where you are applying -- ex. surgery, internal medicine) *

***COVERAGE IS LIMITED TO CLINICAL ACTIVITIES AND PROCEDURES AS DESCRIBED BY YOU IN THIS APPLICATION***

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 surgical procedures *

Will you be assisting in any obstetrical procedures? *

Yes No

If yes, please list the obstetrical procedures *

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

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

Contact email of elective coordinator where you are applying *

How did you hear about us? *

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.

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