Apply for Membership

Below you will find the required forms that you will need to apply for insurance coverage with Healthcare Providers Insurance Exchange. There are “basic” and “state specific” forms. Please be sure to choose the state specific forms based upon your desired coverage area.

• CEO Commentary; Welcome Letter (PDF)
• HPIX Info Statement (PDF)

Basic Forms:

• Application for Physician (PDF)
• Application for Entity (PDF)
• Subscribers Agreement (PDF)
• Surplus Contribution Agreement (PDF)
• Claim Supplement Form (PDF)
• Office Practice Questionnaire (PDF)

State Specific Forms:

New Jersey

• Application for Physician – NJ (PDF)
• Application for Entity – NJ (PDF)
• Application for Allied Employees (PDF)
• Application for Supplemental Prior Acts – NJ (PDF)

Maryland

• Application for Part-Time Discount – MD (PDF)
• Patient Load Questionnaire - MD (PDF)
• Application for Ancillary Employees – MD (PDF)