ProAssurance's Annual Baseline Self-Assessment Request Form

Initiating the ABSA Process

Thank you for your interest in the ABSA. Please provide some information so we can connect you with a local consultant. Once submitted, you'll receive a unique assessment link for your practice within a couple days along with instructions for completing the assessment.

POTENTIAL POLICY DISCOUNT

Participation in the Annual Baseline Self-Assessment (ABSA) may qualify ProAssurance physicians for premium credit upon completion of the assessment. Physicians who participate in the LPS and ABSA programs may apply the Risk Management premium credit only once. Contact your ProAssurance agent or business development manager to see if you qualify. Premium credits are subject to approval by the state insurance department and are applied at policy renewal if applicable.

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* 1. Medical Practice Name (only one request is necessary per medical practice)

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* 2. Policy Number (if known)

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* 3. State your practice is located in (two letter format, e.g., FL):

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* 4. Please check the box if the medical practice a member of:

The OBRA program

Certitude or Ascension

Wismed

E & S

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* 5. Name of person filling out the request:

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* 6. Your contact email address:

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* 7. Your contact phone number

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* 8. Are you the manager or administrator for the medical practice?

Yes

This practice does not have someone in the manager/administrator role.

25% of survey complete.