General Information Your Name: Your E-Mail Address: Primary Practice Address: City: State:  Zip:  County: 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:     Retroactive Date: Premium: $

 

Professional Information Occupation: Specialty: Practice Operates: Full Time Part Time Board Certified 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: $

 

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