Agents & Brokers – Health Center FTCA Gap Coverage

Health Centers

Items Needed to Obtain a Quote

1. Completed Health Center FTCA Facility Medical Malpractice and CGL application for the named insured, a separate Health Center Physician Application and a Health Center Dentist Application for every physician and every dentist who requires coverage
2. Latest audited financial statement
3. Insurance company loss runs, at least 5 years
4. FTCA deeming letter s
5. Signed Brokerage Agreement and W9 Form

PLEASE RETURN ALL ITEMS TO

Alan Labadorf, CPCU
Managing Director
Brown & Brown Garden City
595 Stewart Ave
Garden City, NY 11530
alabadorf@bbinsgc.com
(516) 247-5803