Claims History Request from a Physician No Longer Insured by CRICO

Please complete this form. Upon submission, you will be directed to the payment page where you can remit the $25 claims history processing fee using PayPal.
* = required field

Requirements for Claims History Requests

Degree not on list?
Enter yours here.

Delivery & Support Information

If you have the contact's email, please include it in "Note to Underwriting."

Confirmation and Follow-Up

By checking the box, you are confirming that you are the former CRICO-insured provider. Further, you acknowledge that you have verified the recipient email address above.