This form is intended for ProAssurance customers requesting deferred cancellation due to non-payment of premium as a result of hardships experienced due to the COVID-19 pandemic.
 
Complete this form to request:
  • Automatic bank drafts from your subscription to an electronic payment plan (EPP) be suspended; OR
  • Consideration for cancellation deferral for payments due outside of the current deferral period beginning 4/2/2020 and ending 6/29/2020.

There is no need for policyholders to complete this form who are not on EPP or whose deferral needs are within the current cancellation deferral period. You may continue to receive invoices/statements by mail, however your policy will not be cancelled due to failure to pay, provided payment is received by 6/30/2020.

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* 1. Policyholder name

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* 2. Policy number

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* 3. Practice state

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* 4. Name & company of person submitting this request

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* 5. Contact phone & email address

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* 6. I am requesting:

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* 7. Summary of circumstances/reasons for making this request. Please include requested deferral dates.

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* 8. If you have documentation or correspondence to upload, please do so here

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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Upon submission, this form will be routed to the appropriate service team for consideration. Your designated underwriter will confirm receipt and provide a response within two business days.

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