Please complete this form to receive your quote from The Doctors Company RRG.
The undersigned hereby affirms that I am authorized to provide consent on behalf of the Practice and do hereby grant explicit consent and authorization for NJ PURE to disclose all the Practice files in the
possession of NJ PURE relevant to policy applications and renewals, to The Doctors Company Risk Retention Group (“TDCRRG”) for the purpose of enabling TDCRRG to provide a quote in connection with the potential
issuance of a medical malpractice insurance policy (the “Purpose”). This authorization covers the complete underwriting file, policy terms, conditions, endorsements, and any other relevant documents and information
associated with the Purpose stated herein.
I understand that this authorization will remain effective from the date of signature until such time the Practice is no longer insured by NJ PURE, and that the disclosure of documents and information as stated
herein shall only be made in connection the Purpose and will be handled confidentially in compliance with all applicable federal and state laws. I understand that I may, upon written request to NJ PURE, be
provided with a written electronic copy via Email of the documents that were sent to TDCRRG, and that the authorization may be revoked at any time by written, dated communication to NJ PURE.
The information entered below signifies your consent and will serve as your legal signature.
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