First Professionals Insurance Company

In Order to assist our agents, FPIC has placed our most requested forms on the website. To obtain a copy of the form, click on the form and then print it.

Physician/Surgeon Application
Ancillary Employee Application
Endorsement Request Form		This form is used when requesting any policy endorsements. The supporting documentation must also be included.
Application for Rate Discount: Part Time Discount		This form should be completed at renewal by physicians seeking to receive the part-time physician discount.
Application for Increased Policy Limits		This form must be completed by physicians requesting an increase their limits of liability. Increased limits must be approved by FPIC.
Request for Decreased Limits of Liability		This must be completed by physicians requesting to decrease the limits of liability.
Locum Tenens Acknowledgement		This form will temporarily add a physician to the coverage.
Affidavit of Retirement
Policy Form - For Florida Physicians Only

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FPIC 1000 Riverside Ave. Suite 800,
Jacksonville, FL 32204 Tel: 800.741.3742 Fax: 904.358.6728