Application Instructions for UMIA Liability Policies

Print, complete, sign and mail forms to UMIA. Forms may not be completed online and must be signed and on file at UMIA.

An individual application and Power of Attorney is needed for all applicants.

The Prior Acts application applies only to those individuals transferring coverage from another company who have practiced in the UMIA coverage area.

If you practice in a group or as a member of a partnership/corporation/LLC, an additional named insured or separate corporate/partnership/LLC application is also needed.

Declaration Sheet From Prior Liability Insurer: As part of the application, you MUST furnish UMIA a copy of the Declaration Sheet from your current/prior liability insurer. This is not necessary if you are entering practice for the first time or have just completed your training. Please indicate on Page 3 of the Individual Application the type of coverage provided through your training program.

Send completed forms to:
UMIA
310 East, 4500 South, Suite 550
Salt Lake City, Utah
84107-3993

Forms and Descriptions

NOTE: To View and Print a UMIA application forms you need Adobe Acrobat Reader. If you do not have this program, click here to download your free copy.

Individual Application | Download PDF
Print or type, complete, sign and date the application for insurance. Be sure to answer all questions and provide supporting information. Failure to provide the necessary information will delay the processing of your application.

Membership Application-Power of Attorney | Download PDF
Print or type, sign, and date the Power of Attorney. Enter your name and residence address on the lines indicated on Page 4.

Prior Acts Coverage Application | Download PDF
Prior Acts Coverage allows you to transfer your liability coverage to UMIA without having to purchase “tail coverage” or an extended reporting endorsement from your previous liability insurer. Fill this application out only if you have been in practice in the UMIA coverage area (Utah, Idaho, Wyoming, or Montana), and you are applying for coverage from UMIA. Complete the form and its attachment, sign, and date both. This application will be reviewed by the Underwriting Department staff to determine if you meet UMIA criteria for this coverage. You will be notified if you do or do not qualify. If you do not qualify, purchase of “tail” coverage from your prior liability insurer is necessary.

Additional Named Insured for Corporate/Partnership Coverage Application: Two types of Corporate/Partnership Coverage/LLC are available.

Additional Named Insured | Download PDF
All members of a group must be insured by UMIA to have the Corporation/Partnership/LLC named as an Additional Named Insured on the policies of the individual physicians. The entity shares the limit of liability with the individual physicians. There is no additional premium to have an additional named insured on a policy.

Independent Corporation/Partnership/LLC | Download PDF
This coverage is available to groups comprised of two or more physician and provides an additional, separate coverage limit. There is a separate premium for independent coverage.

Additional Applications

Locum tenens | Download PDF
Application for a locum tenens physician to work in your practice or group as an additional named insured.

Additional Named Insured Ancillary Personnel | Download PDF
Application for adding ancillary personnel such as a nurse or technician as an additional named insured under physician coverage.