Enrollment Application


Enrollment for Doctor.com and MLMIC Insurance Company’s Preferred Savings Program: Doctor.com Risk Purchasing Group (RPG)

I request to enroll in Doctor.com and the Doctor.com Risk Purchasing Group. My Enrollment in Doctor.com will be governed by the following Terms of Service and Business Associates Agreement:



This is an application for potential qualification for membership in the Doctor.com Risk Purchasing Group (RPG).  Risk Purchasing Groups are entities created to seek out and administer possible relationships within a communal organization (such as membership to the same IPA) whereas a benefit(s) may be secured from outside service providers – such as insurance companies. The feasibility and success of any Risk Purchasing Group’s ability to achieve discounted insurance premiums for its members is predicated by the NYS Department of Financial Services that its members have better than average loss experience. Therefore, in order to ensure viability of this program, parameters as to membership in the RPG have been set by the RPG and not all physicians who apply for membership therein will qualify. The factors as to qualification include, but are not limited to, your loss history, claims experience, and other eligibility criteria.

By completing the following application, you acknowledge your understanding and acceptance of the application process, participation requirements and terms of this program. (Ed.12-2019)

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