Professional Liability Insurance

(All forms are in PDF format. If you cannot print a form, please call 1-800-221-3083 and we will be glad to mail forms to you.)
Form / Link Purpose

Enrollment Form with Rate Chart To participate in the Professional Liability Insurance Plan, an Enrollment Form must be completed, signed and mailed to Mass Benefits Consultants, Inc. The Enrollment Form includes the Bi-Weekly, Quarterly, Semi-Annual, and Annual premium rates.

Direct Deposit Form Complete this form if you want to pay by payroll deduction and your Payroll office processes the form.

Employee Express Form Use this information if you want to pay by payroll deduction and you must start the deduction yourself through HR Links or Employee Express online.

Receipt of Payment When you are ready to submit your request for reimbursement to your agency, complete and mail or fax this form to us. If you pay by Payroll Deduction, please remember that the receipt will reflect the pay periods received.

Claims If you have received notice of an Administrative Hearing or been served with a lawsuit, contact us immediately at 1-800-221-3083 or fax a notice to 703-642-2240. Be sure to include your name and daytime phone number.