Once the Quote form is completed a representative will contact you. Please fill out our long form Membership Application for a more thorough answer for your quote.

Mail / Fax : If you would like to print and fill out this application by hand click here. and mail it in please click here for download. When completed mail to : 110 Veterans Boulevard, Suite 360, Metairie, Louisiana 70005-4930 or FAX to  (504) 836-2860

To access Application please click here.

Questions? Feel free to call us today at (504) 834-6240

Fields marked with a * are required

Renewal Application Instructions

  1. All questions must be answered. Please do not leave any blanks. If a question is not applicable, please write N/A.
  2. Please indicate any desired changes in the appropriate area.
  3. Application must be signed and dated by applicant in ink.

This is an application for insurance, not an insurance binder. Completion of this form neither binds coverage nor guarantees that a policy will be issued. Additional Information may be required upon review of the application

Enter all claims (regardless of fault) or occurrences that may give rise to claims for the prior 5 years


Per Claim $100,000
Certificate Aggregate $300,000
Master Policy Program Aggregate $2,000,000

Additional Provisions
This physician has qualified under ACT 817, the Louisiana Patients’ Compensation Fund

By hitting Submit I hereby acknowledge that the aforementioned statements and answers are correct and complete. I further understand that any incorrect or incomplete statement could void my protection. I hereby authorize Louisiana Premier Physicians Program to release the information on this application and associated underwriting information.