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Great Northern Insurance Agency
Our Dedication Ensures Your Satisfaction

CALL NOW 248-856-9000

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Insurance
Free Quotes
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Calculators
Contact Us

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Insurance
Free Quotes
Service Center
Calculators
Contact Us

Professional Liability

Our process is transparent

For Help Call 1-(248)-856-9000

GENERAL INFORMATION

Fields marked (*) are mandatory

YOUR NAME

YOUR E-MAIL ADDRESS

PRIMARY PRACTICE ADDRESS

CITY

STATE

ZIP

OFFICE PHONE

OFFICINE FAX

DATE OF BIRTH

LICENSE NUMBER

PRACTICE INFORMATION

Fields marked (*) are mandatory

INDIVIDUAL

PARTNERSHIP

ASSOCIATION

GROUP PRACTICE

PROFESSIONAL CORPORATION

AFFILIATION

OTHER

CURRENT PROFESSIONAL LIABILITY COVERAGE

CURRENT INSURANCE CARRIER

LIMIT OF LIABILITY PER CLAIM ($)

LIMIT OF LIABILITY AGGREGATE ($)

EFFECTIVE DATE

RETROACTIVE DATE

PREMIUM ($)

PROFESSIONAL INFORMATION

OCCUPATION

SPECIALTY

PRACTICE OPERATES

Full Time Part Time

BOARD CERTIFIED

Yes No

CLAIMS HISTORY (THIS INFORMATION IS KEPT STRICTLY CONFIDENTIAL)

Fields marked (*) are mandatory

Claim #1

CLAIM STATUS

Closed Open

CLAIMANT NAME

DATE OF OCCURRENCE

INSURANCE CARRIER

LOCATION OF OCCURRENCE

ALLEGATIONS

AMOUNT PAID ON YOUR BEHALF ($)

AMOUNT RESERVED ON BEHALF ($)

Claim #2

CLAIM STATUS

Closed Open

CLAIMANT NAME

DATE OF OCCURRENCE

INSURANCE CARRIER

LOCATION OF OCCURRENCE

ALLEGATIONS

AMOUNT PAID ON YOUR BEHALF ($)

AMOUNT RESERVED ON BEHALF ($)

Claim #3

CLAIM STATUS

Closed Open

CLAIMANT NAME

DATE OF OCCURRENCE

INSURANCE CARRIER

LOCATION OF OCCURRENCE

ALLEGATIONS

AMOUNT PAID ON YOUR BEHALF ($)

AMOUNT RESERVED ON BEHALF ($)

ADDITIONAL COMMENTS

ADDITIONAL COMMENTS

Products

Services

Locations

Products

Auto Quote
Homeowners Quote
Condominium insurance
Renters Insurance
Commercial Auto
Business Owners (BOP)
General Liability
Inland Marine
Liquor Liability

Services

Change Address
Add Vehicle
Delete Vehicle
Change Vehicle
Add Driver
Delete Driver
General Auto Request
File Auto Claim
General Home Request
File Property Loss

Locations

Main Office
ISU-Great Northern Insurance Agency 39850 Van Dyke Ave Sterling Heights , MI 48313
Phone:248-856-9000
Fax:248-856-9001
California Office
Kevin Lam 1900 Camden Ave San Jose, CA 95124
Phone:(408) 444-5196
Fax:(877) 275-1639
Ann Arbor Office
Kristine Reed PO Box 3306 Ann Arbor, MI 48106
Phone:(734)945-0027
Phone2:(248)856-9000
Fax:(248)856-9001

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