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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