Before completing this form, please read:

If you have no patient contact at this time and you're requesting a leave of absence, please complete this form instead of the form below.
If you typically work directly with one of our agent partners, please contact your agent to discuss your change in patient contact hours.

Submit Change in Patient Contact Hours

Note: A change in patient contact hours may result in a change in premium. All policy changes are subject to Underwriting review and approval.

First name*

Last name*

Policy Number (if available)

State/Region

Email*

Phone number*

Preferred Contact Method*

Start date*

*Start date can be no more than 30 days from the day this form is submitted.

If requesting to backdate more than 30 days, please provide a narrative as to your personal situation for review.

Current Patient Contact Hours Per Week, Including Telemedicine

NOTE:

If you have no patient contact at this time and you're requesting a leave of absence, please complete this form.
Part time hour requirements and discounts vary by state.
We are monitoring state regulatory changes and adjusting accordingly. A temporary part time status may not be available to those who participate in the patient compensation funds (PCF) in Indiana, Kansas, and Louisiana. We will update this information once the PCF makes this information available.

Any additional information you would like us to know?

PLEASE CONTACT US WHEN YOUR PRACTICE INFORMATION CHANGES