Applications & forms

Explore our applications and forms below.

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We welcome the opportunity to speak with you about finding the right coverage for your unique situation. If you have questions, feel free to call 864.240.5449 or 866.893.6270, and we will gladly assess your risk and discuss your coverage options.

To apply for coverage, please download the appropriate form below and return it with all required materials, such as current declarations, curriculum vitae, a loss history report and other materials. When your form has been completed, please send the form to Peggy.McCall@marsh.com. 

Unless otherwise requested, all MMA insured individual physicians, dentists and allied healthcare providers will receive renewal quotes based upon the information currently in our system.

Hospitals and other medical facilities are required to submit renewal applications each year.

Physicians

Application for Physicians.
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Allied Healthcare professional

Application for optometrists, pharmacists, physicians assistants, registered nurses, nurse practitioners, nurse anesthetists, and nurse midwives.
Download Form

Dental and Oral Surgeons

Application for dentists and oral surgeons.
Download Form

Healthcare Facility - New

This is a new business application for medical professional liability insurance from SCJUA. It is intended for us by outpatient surgery centers, diagnostic centers, endoscopy centers, free/non-profit clinics, and other facilities who are NOT currently insured by SCJUA.
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Healthcare Facility - Renewal

This is a renewal application for medical professional liability insurance from SCJUA. It is intended for us by outpatient surgery centers, diagnostic centers, endoscopy centers, free/non-profit clinics, and other facilities who are currently insured by SCJUA.
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Locum Tenens Healthcare Provider

Written request for Locum Tenens coverage approval for a substitute healthcare provider must be made in advance using this application. Locum Tenens coverage cannot be provided on a retroactive basis if the request is made late. Every effort will be made to advise the applicant within 48-hours if they are eligible for Locum Tenens coverage through the JUA. If a physician is determined to be eligible, his/her approved application will be in effect for one year.
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Part Time Credit

art time Healthcare Provider credit application must be completed by the applicant every year for the purposes of determining whether the applicant is eligible for this type of coverae. The hours reported to the SCJUA are for rating purposes and are subject to audit at the SCJUA’s discretion.

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Practice Entity - NEW

his is a NEW BUSINESS application for medical professional liability insurance from the SCJUA. It is intended for use by practice entities that are currently insured by the SCJUA. Practice entities are required to submit a renewal application annually.
Download Form

Practice Entity - RENEWAL

This is a RENEWAL application for medical professional liability insurance from the SCJUA. It is intended for use by practice entities that are currently insured by the SCJUA. Practice entities are required to submit a renewal application annually.
Download Form

Additional Insured Vicarious Liability Endorsement Request

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Authorization To Release policy information

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Broker Information

Required form for agents/brokers who place business with SCJUA, or who are registering for a listing in “Find an Agent” on SCJUA.com
Download Form

Dentist and Oral Surgeon Procedures Requests

Download Form

Entity Shared Limits Endorsement Request

Download Form

Insured Address Change Request

Download Form

Loss Notice

Download Form

Midlevel Shared limits Endorsement Request

Download Form

Occurrence to claims made request

Download Form

Policy Cancellation Request

Download Form

Renewal Questionnaire for Cardiology, Pathology, and Radiology

Download Form

Locum Tenens Coverage Request Form

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Contact Us

We welcome the opportunity to answer any questions you have regardless of your current insurance provider. For time sensitive requests, please contact a MMA colleague directly.  The MMA cannot bind or alter coverage based on instructions received through our Contact Us form.

Local: 864-240-5449
Toll-free: 866-893-6270
Fax: 864-240-2750

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