General Information
Your Name:
Your E-Mail Address:
Primary Practice Address:
City:	County:   State:   Zip:
Office Phone:	Office Fax:
Date of Birth:	License Number:

 

Practice Information

Check each that applies to your practice

Individual Group Practice Partnership Professional Corporation Association Affiliation Other:

 

Current Professional Liability Coverage
Current Insurance Carrier:
Limits of liability:	$ per claim       $ aggregate
Effective Date:	Premium: $   Retroactive Date:

 

Professional Information
Occupation:	Practice Operates:	Board Certified
Specialty:	Full Time Part Time	Yes No

 

Claims History This information is kept strictly confidential

Claim #1	Claim Status: Closed   Open
Claimant Name:	Date of occurrence:
Insurance Carrier:	Location of occurrence:
Allegations:
Amount paid on your behalf:	$   Amount reserved on behalf: $

Claim #2	Claim Status: Closed   Open
Claimant Name:	Date of occurrence:
Insurance Carrier:	Location of occurrence:
Allegations:
Amount paid on your behalf:	$   Amount reserved on behalf: $

Claim #3	Claim Status: Closed   Open
Claimant Name:	Date of occurrence:
Insurance Carrier:	Location of occurrence:
Allegations:
Amount paid on your behalf:	$   Amount reserved on behalf: $

 

Additional Comments

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