INDIVIDUAL APPLICATION FOR CLAIMS-MADE AND REPORTED DENTISTS PROFESSIONAL LIABILITY INSURANCE

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "INDIVIDUAL APPLICATION FOR CLAIMS-MADE AND REPORTED DENTISTS PROFESSIONAL LIABILITY INSURANCE"

Transcription

1 Home Office: Madison, Wisconsin Administrative Office: 8877 North Gainey Center Drive Scottsdale, Arizona INDIVIDUAL APPLICATION FOR CLAIMS-MADE AND REPORTED DENTISTS PROFESSIONAL LIABILITY INSURANCE The following are representations of facts known by you to be true. You agree that any coverage issued will be contingent upon the truth and upon final approval by National Casualty Company. If a policy is issued, this application will become part of the policy. Please fully complete this application, as an incomplete application cannot be evaluated. TO EXPEDITE THE EVALUATION PROCESS AND ALLOW US TO GET A RESPONSE BACK TO YOUR INSUR- ANCE BROKER AS QUICKLY AS POSSIBLE, PLEASE REMEMBER TO: (A) PLEASE PRINT IN INK OR TYPE AND FULLY COMPLETE THE APPLICATION. (B) PLEASE SIGN AND DATE THE APPLICATION. (C) PLEASE ANSWER ALL QUESTIONS UNLESS SPECIFICALLY INSTRUCTED OTHERWISE. (D) PLEASE PROVIDE THE REQUIRED DOCUMENTATION REQUESTED ON PAGE 7. (E) IF YOU ARE REQUIRED TO COMPLETE ANY SUPPLEMENTS, PLEASE BE SURE THAT ALL QUES- TIONS ON THOSE SUPPLEMENTS ARE ANSWERED AND THAT YOU SIGN AND DATE EACH SUPPLE- MENT. (SPECIFIC INSTRUCTIONS ARE ALSO PROVIDED ON EACH SUPPLEMENT.) I. ABOUT YOU 1. Name: 2. Date of Birth: 3. Social Security No.: 4. Professional Degree: DDS DMD Other: 5. Mailing Address: Street City County State Zip 6. Business Telephone No.: 7. Business Fax No.: 8. Residence Telephone No.: 9. Business Address: 10. Practice Web site Address: 11. Dental School: 12. Year Graduated: 13. Date You Began Practice: 14. Specialty School (if any): 15. Year Graduated: 16. Specialty: 17. Dental/Medical License Number(s) States(s) Expiration Date(s) DT-APP-4 (2-07) Page 1 of 6

2 18. Please provide the name(s) of your professional liability carrier(s) for the last three years, premium, policy number, limits and coverage dates. Also, please check if the policies were claims-made or occurrence types. Insurer Premium Policy No. Policy Limits Policy Period Type II. ABOUT THE PROPOSED POLICY Claims-Made Occurrence Claims-Made Occurrence Claims-Made Occurrence 19. Requested coverage effective date: Retroactive Date: 20. LIMITS OF LIABILITY DESIRED (Per Claim/Aggregate). Some limits are not available in certain states. $100,000/$300,000 $200,000/$600,000 $500,000/$1,500,000 $1,000,000/$3,000,000 $2,000,000/$4,000,000 $3,000,000/$3,000, Have you practiced without professional liability insurance in the last ten (10) years?... Yes No If Yes, explain in remarks section. 22. Has there been a professional liability claim or suit (settled or pending) made against you within the last five years?... Yes No If Yes, complete a separate Claim/Incident Supplement for each such claim or suit. 23. Within the past five years, have you had knowledge of any dental incident or activity which might give rise to a claim against you?... Yes No If Yes, complete a Claim/Incident Supplement for each matter and advise whether or not you have reported each matter to your professional liability insurance company. 24. Has any insurer canceled, declined, rescinded or modified coverage, or refused renewal?... Yes No If Yes, explain in remarks section. (Not applicable to Missouri applicants) 25. Has any governmental, peer review committee, hospital, professional association, patient or licensing agency ever investigated you, or suspended, revoked, placed on probation, reprimanded or taken any other action against you, your narcotics license or your license(s) to practice dentistry?... Yes No If Yes, provide a written explanation and attach a copy of the decree. 26. Do you have or have you had any physical disability or injury, personal health problems, including alcoholism, narcotics addiction or mental illness which affected your ability to practice dentistry?... Yes No If Yes, explain in remarks section and attach a current statement from your attending physician regarding your ability to treat patients. 27. Have you ever had complaints filed against you involving the administration of Medicare/Medicaid or patient insurance?... Yes No If Yes, explain in remarks section. 28. Are you an active member of your state dental association or an accredited dental association?... Yes No If Yes, please provide name of the association(s): DT-APP-4 (2-07) Page 2 of 6

3 III. ABOUT YOUR PRACTICE 29. As to your practice of dentistry, please complete the following: A. Do you practice as an employee or independent contractor with no ownership interest?... Yes No If Yes, please list below the locations where you work. The percentages must total 100. PLEASE COMPLETE IF YOU ARE AN EMPLOYED DENTIST OR AN INDEPENDENT CONTRACTOR. Legal Practice Name Owner(s) Address, including County Employee I/C Practice Time at Each Location B. Do you own your own practice?... Yes No C. Do you have ownership interest in more than one practice?... Yes No If Yes, how many practices do you own? D. If you own your own practice, do you also work as an employed dentist or independent contractor at another location?... Yes No If Yes, please complete the chart above for the non-owned location(s) and complete the Practice Ownership Supplement for the location you own. IF YOU ANSWERED QUESTIONS 29.B., 29.C. OR 29.D. YES, PLEASE COMPLETE THE PRACTICE OWN- ERSHIP SUPPLEMENT. 30. Do you share dental facilities with another dentist other than your partners, corporate officers, employees or independent contractors?... Yes No If Yes, please attach proof of dentists professional liability insurance for the other dentist(s) in that facility sharing arrangement (copies of current Declarations Pages or current Certificates of Insurance will suffice). 31. Do you have a contract to provide dental services with a hospital, clinic or other commercial or charitable entity (other than a private dental practice)?... Yes No NOTE: Please provide a copy of all such contracts. 32. Total number of hours YOU practice per week at all locations: If you practice twenty (20) hours or less per week on average: a. What date did you begin this schedule? / / b. When do you expect to begin practicing over twenty (20) hours per week on average? 33. Number of patients YOU treat per month: 34. What percentage of those patients are under age sixteen (16)? Are you a full-time student enrolled in an accredited dental post-doctoral program?... Yes No 36. Are you a full-time dental school faculty member?... Yes No If Yes, please provide name of school: 37. Have you taken a Risk Management Course or Seminar during the last three years?... Yes No If Yes, please provide a copy of certificate or transcript for a possible credit. DT-APP-4 (2-07) Page 3 of 6

4 IV. OFFICE PROCEDURES 38. What type of informed consent do you use? Oral Written None If oral, is chart noted, dated and initialed by the patient?... Yes No If written: a. Who reviews the consent form with the patient prior to treatment? b. Is the consent form available in the patient s language if the patient does not speak English?... Yes No 39. Do you obtain a complete patient medical history?... Yes No 40. How often do you or your staff update patient histories? Each visit Occasionally No policy If occasionally, what is your procedure? Do the answers to the above questions 39. and 40. apply to all locations where you practice?... Yes No If No, please explain on a separate sheet or in the remarks section. Anesthesia/Analgesia: 41. Are patients treated in your office with: a. Local anesthesia?... Yes No b. Nitrous oxide?... Yes No c. Chloral Hydrate?... Yes No d. Oral Premeds?... Yes No If Yes, who administers this anesthesia? You Another dentist Anesthesiologist or CRNA 42. Are patients treated in your office under conscious sedation?... Yes No If Yes : a. Who administers the anesthesia? You Another dentist Anesthesiologist or CRNA b. Is it administered via I.V. or I.M.?... Yes No c. If administered by another dentist, is the dentist licensed to provide anesthesia?... Yes No d. Is this dentist YOUR employee?... Yes No e. If administered by an Anesthesiologist or CRNA, is that person YOUR employee?... Yes No 43. Are you treating patients who are under general anesthesia/deep sedation?... Yes No If Yes, where are the procedures performed? In your office In a hospital or surgical center a. If In your office, who administers the anesthesia? You Another dentist Anesthesiologist or CRNA b. Is it administered via I.V. or I.M.?... Yes No c. If administered by another dentist, is the dentist licensed to provide anesthesia?... Yes No d. Is this dentist YOUR employee?... Yes No e. If administered by an Anesthesiologist or CRNA, is that person YOUR employee?... Yes No IF I.V., I.M. OR GENERAL ANESTHESIA IS USED, YOU MUST COMPLETE THE ANESTHESIA SUPPLEMENT. V. ABOUT YOUR PROCEDURES 44. Are you a: General Dentist or Specialist If you are a Specialist, please list Specialty: Specialty training: If you are a Specialist and also perform procedures in another area of dentistry, please specify the area(s) and please estimate the time spent practicing in these areas: DT-APP-4 (2-07) Page 4 of 6

5 45. DURING A TYPICAL PRACTICE MONTH, WHAT PERCENTAGE OF YOUR TIME IS DEVOTED TO EACH OF THE FOLLOWING PROCEDURES? (PERCENTAGES SHOULD ADD UP TO 100) a. Diagnostic (exams, X-rays, etc.):... b. Preventive (fluoride, prophylaxis, patient education, pit and fissure sealants, etc.):... c. Restorative (single-unit restorations):... d. General services (patient management):... e. Prosthodontic (fixed and removable multi-unit restorations):... f. Endodontics:... g. Periodontics:... h. Pedodontics:... i. Orthodontics:... j. Treatment for TMJ/TMD:... k. Oral Surgery: If YOU show a percentage in the Oral Surgery item 45.k. above, please specify which procedure(s) you perform: Simple extractions Third molar extractions (please specify type(s) below) Amount of monthly practice time:... Soft tissue impactions Partial bony impactions Total bony impactions Describe any other surgical procedures YOU perform, including surgical periodontic procedures: Amount of monthly practice time for these other surgical procedures: Do you currently use paraformaldehyde or heavy-metal Sargenti type compounds in any dental procedure?... Yes No Have you ever used paraformaldehyde or heavy-metal Sargenti type compounds in any dental procedure?... Yes No If Yes, when did you last use it? 48. Do you provide any restorative or surgical implant services?... Yes No If Yes, please complete Implant supplement. 49. Do you perform TMJ/TMD procedures?... Yes No If Yes, please complete TMJ/TMD supplement. 50. Do you use lasers?... Yes No If Yes, please complete laser supplement. VI. REMARKS SECTION (please indicate question number to which your response pertains) DT-APP-4 (2-07) Page 5 of 6

6 VII. APPLICANT S STATEMENT/SIGNATURE I understand that this application is for a Dentists Professional Liability Insurance Policy and is subject to acceptance by the insurance company. I understand that I must immediately report any claim or potential claim to my insurance representative or directly to the Company. Important notice: Your agent can provide a copy of the policy form for you to evaluate. For complete and specific details of Coverage, conditions, limitations and exclusions, be sure to read the policy, including any attachments to it. I understand that any policy issued will rely on the truth of the statements and representations I have made herein and that misrepresentations that are fraudulent, or such that the Company would not have issued the policy if the true facts had been known, may result in a denial of coverage for any claim which may be made under this insurance. I understand that by completing and submitting this application for insurance, I am also applying for membership in the Dental Professionals Purchasing Group, a risk purchasing group formed for the sole purpose of providing professional liability insurance to dentists. My sole purpose in becoming a member is to purchase professional liability insurance. FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. FRAUD WARNING (Applicable in Tennessee and Washington): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Applicant s Signature Date Agent Name: Agent License No.: (Applicable to Florida Agents Only) Iowa Licensed Agent: (Applicable to Iowa Agents Only) COMPLETION OF THIS FORM NEITHER BINDS COVERAGE NOR GUARANTEES A POLICY WILL BE ISSUED. Please attach a copy of: Your current insurance Declarations page including retroactive date. Certificate or Transcript evidencing completion of risk management course or seminar within the last three years for possible premium credit (if you answered Yes to question 37.). Your practice letterhead. Contracts, if any, with hospitals, clinics or any commercial or charitable entity other than a private dental practice (if you answered Yes to question 31.). Evidence of dentists professional liability insurance for: a. your co-owners (per the PRACTICE OWNERSHIP SUPPLEMENT ). b. your employee dentist(s) and/or the independent contractor dentist(s) in your practice (per the PRAC- TICE OWNERSHIP SUPPLEMENT ). c. dentists in office-share arrangements (if you answered Yes to question 30.). Please note that exclusions may apply. Read your policy carefully. DT-APP-4 (2-07) Page 6 of 6

INDIVIDUAL APPLICATION FOR CLAIMS-MADE DENTISTS PROFESSIONAL LIABILITY INSURANCE

INDIVIDUAL APPLICATION FOR CLAIMS-MADE DENTISTS PROFESSIONAL LIABILITY INSURANCE Madison, Wisconsin Property/Casualty Home Office 8877 North Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 Fax (480) 483-6752 INDIVIDUAL APPLICATION FOR CLAIMS-MADE DENTISTS PROFESSIONAL

More information

Professional Liability Application for Dentists

Professional Liability Application for Dentists Dentists Benefits Insurance Company Northwest Dentists Insurance Company Professional Liability Application for Dentists THIS IS AN APPLICATION FOR CLAIMS MADE COVERAGE WHICH, SUBJECT TO ITS PROVISIONS,

More information

ALLIED MEDICAL DENTAL PROFESSIONAL SUPPLEMENTAL APPLICATION Submit with Allied Medical General Application

ALLIED MEDICAL DENTAL PROFESSIONAL SUPPLEMENTAL APPLICATION Submit with Allied Medical General Application ALLIED MEDICAL DENTAL PROFESSIONAL SUPPLEMENTAL APPLICATION Submit with Allied Medical General Application Every statement MUST be completed. Write NONE if that applies. PLEASE TYPE OR PRINT. SECTION I:

More information

Application for Coverage Professional & Business Liability Insurance

Application for Coverage Professional & Business Liability Insurance Application for Coverage Professional & Business Liability Insurance Please type or print Please read this before filling out your application for Professional & Business Liability insurance. You warrant

More information

DENTIST S PROFESSIONAL LIABILITY APPLICATION

DENTIST S PROFESSIONAL LIABILITY APPLICATION NEW RENEWAL OF POLICY NUMBER ADD L DENTIST TO POLICY NUMBER DENTIST S PROFESSIONAL LIABILITY APPLICATION The Cincinnati Insurance Company The Cincinnati Casualty Company The Cincinnati Indemnity Company

More information

Application for Claims-Made Coverage Professional & Dental Business Liability Insurance

Application for Claims-Made Coverage Professional & Dental Business Liability Insurance Please type or print Please read this before filling out your application for Professional & Business Liability insurance. You warrant and represent that the following statements are yours and that you

More information

Dental Professional Liability Insurance Application - Individual Dentist

Dental Professional Liability Insurance Application - Individual Dentist Dental Professional Liability Insurance Application - Individual Dentist With your fully completed, signed and dated application, you must submit the following information: 1. Current insurance policy

More information

Dental Professional Liability Insurance Claims-Made Dentist Application

Dental Professional Liability Insurance Claims-Made Dentist Application Dental Professional Liability Insurance Claims-Made Dentist Application ProAssurance Casualty Company PO Box 45650 Madison, WI 53744-5650 800.279.8331 608.831.8331 Fax 608.831.0084 With your fully completed,

More information

Agency Name: Agent Contact: Address: Street City State Zip. Name First Middle Last

Agency Name: Agent Contact: Address: Street City State Zip. Name First Middle Last PSIC Professional Solutions INSURANCE COMPANY Dental Professional Liability Application A. Agency Information Agency Name: Agent Contact: Address: Street City State Zip Office Phone: Email Address: Your

More information

CLAIMS-MADE PROFESSIONAL LIABILITY INSURANCE EXPRESS APPLICATION FOR FDA SERVICES, INC.

CLAIMS-MADE PROFESSIONAL LIABILITY INSURANCE EXPRESS APPLICATION FOR FDA SERVICES, INC. CLAIMS-MADE PROFESSIONAL LIABILITY INSURANCE EXPRESS APPLICATION FOR FDA SERVICES, INC. For Dental Professionals FDA Services 1113 E. Tennessee Street Tallahassee, Florida 32308 (800) 877-7597 insurance@fdaservices.com

More information

Fortress Insurance Company

Fortress Insurance Company Fortress Insurance Company Dental Professional Liability Application PLEASE INDICATE THE TYPE OF COVERAGE REQUESTED: ( INDIVIDUAL COVERAGE ( ENTITY COVERAGE ( BOTH I. General Information 1. Name: Suffix:

More information

PHYSICIANS RECIPROCAL INSURERS 1800 Northern Boulevard P.O. Box 9007 Roslyn, NY 11576. (516) 365-2855 Toll Free: (888) 526-4006 THE EXCHANGE

PHYSICIANS RECIPROCAL INSURERS 1800 Northern Boulevard P.O. Box 9007 Roslyn, NY 11576. (516) 365-2855 Toll Free: (888) 526-4006 THE EXCHANGE PHYSICIANS RECIPROCAL INSURERS 1800 Northern Boulevard P.O. Box 9007 Roslyn, NY 11576 (516) 365-2855 Toll Free: (888) 526-4006 THE EXCHANGE APPLICATION FOR DDS/DMD INDIVIDUAL PROFESSIONAL LIABILITY COVERAGE

More information

www.mlmic.com Application For Dentists Professional Liability Insurance

www.mlmic.com Application For Dentists Professional Liability Insurance Medical Liability Mutual Insurance Company NYSDA Endorsed Insurance Program www.mlmic.com Application For Dentists Professional Liability Insurance Home Office Two Park Avenue Room 2500 New York, NY 10016

More information

THE MEDICAL PROTECTIVE COMPANY MULTI-SPECIALTY HEALTHCARE PROFESSIONAL PROFESSIONAL LIABILITY INSURANCE APPLICATION

THE MEDICAL PROTECTIVE COMPANY MULTI-SPECIALTY HEALTHCARE PROFESSIONAL PROFESSIONAL LIABILITY INSURANCE APPLICATION APPLICATION INSTRUCTIONS If previously covered with Medical Protective, or joining a current Medical Protective Healthcare Professional group policy, please enter the Policy Number: THE MEDICAL PROTECTIVE

More information

Allied Health Professional Liability Insurance Application Form

Allied Health Professional Liability Insurance Application Form Allied Health Professional Liability Insurance Application Form THIS APPLICATION IS FOR THE FOLLOWING PROFESSIONALS Physician s Assistant Perfusionist Certified Nurse Practitioner Surgeon s Assistant Optometrist

More information

Allied Health Professional Liability Insurance Application Form

Allied Health Professional Liability Insurance Application Form Allied Health Professional Liability Insurance Application Form With your fully completed, signed and dated application, you must submit the following information: 1. Current insurance policy declarations

More information

Dental Professional Liability Insurance Application Claims-Made

Dental Professional Liability Insurance Application Claims-Made Dental Professional Liability Insurance Application Claims-Made THIS IS AN APPLICATION FOR CLAIMS-MADE COVERAGE WHICH, SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO ANY CLAIM FIRST MADE AGAINST THE INSURED

More information

Dental Professional Liability Insurance Claims-Made Dentist Application

Dental Professional Liability Insurance Claims-Made Dentist Application Dental Professional Liability Insurance Claims-Made Dentist Application ProAssurance Casualty Company PO Box 590009 Birmingham, AL 35259-0009 800.625.7814 Fax 205.868.4040 With your fully completed, signed

More information

THE MEDICAL PROTECTIVE COMPANY MULTI-SPECIALTY HEALTHCARE PROFESSIONAL PROFESSIONAL LIABILITY INSURANCE APPLICATION

THE MEDICAL PROTECTIVE COMPANY MULTI-SPECIALTY HEALTHCARE PROFESSIONAL PROFESSIONAL LIABILITY INSURANCE APPLICATION THE MEDICAL PROTECTIVE COMPANY MULTI-SPECIALTY HEALTHCARE PROFESSIONAL PROFESSIONAL LIABILITY INSURANCE APPLICATION CLAIMS-MADE COVERAGE DISCLOSURE FORM IMPORTANT NOTICE TO INSURED THIS DISCLOSURE FORM

More information

Dental Professional Liability Insurance Occurrence Dentist Application

Dental Professional Liability Insurance Occurrence Dentist Application Dental Professional Liability Insurance Occurrence Dentist Application ProAssurance Casualty Company PO Box 590009 Birmingham, AL 35259-0009 800.625.7814 Fax 205.868.4040 With your fully completed, signed

More information

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE:

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE: APPLICATION FOR PARAMEDICS, EMT S, NURSE ANESTHETISTS, NURSE PRACTITIONERS AND PHYSICIANS AND SURGEONS ASSISTANTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) 1. APPLICANT INFORMATION APPLICANT

More information

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE:

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE: APPLICATION FOR PARAMEDICS, EMT S, NURSE PRACTITIONERS, AMBULANCE SERVICES AND PHYSICIANS AND SURGEONS ASSISTANTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) APPLICANT S INSTRUCTIONS: 1. Answer

More information

1. Legal Name of the Primary Applicant: 3. Corporate Contact Name: 4. Corporate Contact Phone:

1. Legal Name of the Primary Applicant: 3. Corporate Contact Name: 4. Corporate Contact Phone: PSIC RPG Association Large Group Dental Application A. APPLICANT Information 1. Legal Name of the Primary Applicant: 2. of Incorporation or Formation: MO/DAY/YR 3. Corporate Contact Name: 4. Corporate

More information

Employed, Subcontracting or Volunteer Dentist Community Clinic Program Application for Professional Liability Insurance Additional Insured Basis

Employed, Subcontracting or Volunteer Dentist Community Clinic Program Application for Professional Liability Insurance Additional Insured Basis Employed, Subcontracting or Volunteer Dentist Community Clinic Program Application for Professional Liability Insurance Additional Insured Basis Please type or print. Answer all questions. Please note

More information

Dental Professional Liability Insurance Claims-Made Dentist Application

Dental Professional Liability Insurance Claims-Made Dentist Application Dental Professional Liability Insurance Claims-Made Dentist Application ProAssurance Indemnity Company, Inc. PO Box 590009 Birmingham, AL 35259-0009 800.625.7814 Fax 205.868.4040 With your fully completed,

More information

Dentists Professional Liability Application

Dentists Professional Liability Application Return completed application to: Dentist s Advantage 159 East County Line Road Hatboro, PA 19040 Or fax it to 877-250-1527 Questions? Call 866-219-6533 Or visit our website at www.dentists-advantage.com

More information

Allied Healthcare Provider Professional Liability Application

Allied Healthcare Provider Professional Liability Application Allied Healthcare Provider Professional Liability Application 746 Alexander Road, Princeton, NJ 08540-6305 (800) 334-0588 www.princetoninsurance.com Allied Healthcare Provider Professional Liability Application

More information

OMS NATIONAL INSURANCE COMPANY, RRG NEW BUSINESS ENTITY PROFESSIONAL LIABILITY APPLICATION

OMS NATIONAL INSURANCE COMPANY, RRG NEW BUSINESS ENTITY PROFESSIONAL LIABILITY APPLICATION OMS NATIONAL INSURANCE COMPANY, RRG NEW BUSINESS ENTITY PROFESSIONAL LIABILITY APPLICATION In order to expedite the application process, please be sure to answer all questions completely. Please be sure

More information

Dental Corporation Professional Liability Insurance Application

Dental Corporation Professional Liability Insurance Application Dental Corporation Professional Liability Insurance Application ProAssurance Indemnity Company, Inc. PO Box 45650 Madison, WI 53744-5650 800.279.8331 608.831.8331 Fax 608.831.0084 With your fully completed,

More information

Application for Coverage Ancillary This application is for claims made coverage. Please read the policy carefully.

Application for Coverage Ancillary This application is for claims made coverage. Please read the policy carefully. I. Employer Information Agency/Broker: Address: Application for Coverage Ancillary This application is for claims made coverage. Please read the policy carefully. Name of Employer Office Address Street

More information

PROFESSIONAL EMPLOYEE LIABILITY INSURANCE APPLICATION

PROFESSIONAL EMPLOYEE LIABILITY INSURANCE APPLICATION PROFESSIONAL EMPLOYEE LIABILITY INSURANCE APPLICATION All questions must be answered completely. If the answer to any question is NONE or NOT APPLICABLE, so state. Upon receiving a copy of your final application

More information

Berkley Insurance Company

Berkley Insurance Company Lawyers Professional Liability Insurance New Business Application CLAIMS MADE WARNING FOR APPLICATION: This Application is for a Claims Made and Reported Policy, relating to claims made against the Insureds

More information

INDIVIDUAL APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE DENTIST

INDIVIDUAL APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE DENTIST TEXAS MEDICAL INSURANCE COMPANY P.O. Box 160140 Austin,TX 78716-0140 800-580-8658 512-425-5800 fax: 512-425-5998 sales@tmic.biz INDIVIDUAL APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE DENTIST PLEASE

More information

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE:

(PLEASE TYPE OR PRINT IN INK) PART I - ALL APPLICANTS MUST COMPLETE: APPLICATION FOR PARAMEDICS, EMT S, NURSE ANESTHETISTS, NURSE PRACTITIONERS, AMBULANCE SERVICES AND PHYSICIANS AND SURGEONS ASSISTANTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) 1. APPLICANT INFORMATION

More information

California Optometric Association INDIVIDUAL PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR OPTOMETRISTS

California Optometric Association INDIVIDUAL PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR OPTOMETRISTS California Optometric Association OLP INDIVIDUAL PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR OPTOMETRISTS HOW TO APPLY: 1. You may apply on-line at www.proliability.com, or 2. Complete application

More information

Locum Tenens Application EMS Medical Directors Application Checklist

Locum Tenens Application EMS Medical Directors Application Checklist Locum Tenens Application EMS Medical Directors Application Checklist Locum Tenens coverage is only available for a physician who is temporarily substituting for an EMS Medical Director insured for specific

More information

1. Name of applicant Last First Middle. Home Phone FAX number E-mail address. Complete title of your medical professional designation

1. Name of applicant Last First Middle. Home Phone FAX number E-mail address. Complete title of your medical professional designation 2 Park Avenue 8 British American Blvd. New York, NY 10016 Latham, NY 12110 Tel: 212-576-9800 Tel: 518-786-2700 2 Clinton Square 90 Merrick Avenue Syracuse, NY 13202 East Meadow, NY 11554 Tel: 315-428-1188

More information

Real Estate Claims-Made Professional Liability Insurance Application

Real Estate Claims-Made Professional Liability Insurance Application Real Estate Claims-Made Professional Liability Insurance Application Application completion instructions. PLEASE DO NOT USE PENCIL Answer each question completely. If the question does not apply, print

More information

Agency Name: Agency Contact: Address: Street City State Zip

Agency Name: Agency Contact: Address: Street City State Zip PSIC Professional Solutions INSURANCE COMPANY Dental Professional Liability Entity Application A. Agency Information Agency Name: Agency Contact: Address: Street City State Zip Office Phone: Email Address:

More information

Dentist & Oral Surgeon Professional Liability Application

Dentist & Oral Surgeon Professional Liability Application Dentist & Oral Surgeon Professional Liability Application 746 Alexander Road, Princeton, NJ 08540-6305 (800) 334-0588 www.princetoninsurance.com Dentist and Oral Surgeon Professional Liability Application

More information

Specified Professions Professional Liability Product

Specified Professions Professional Liability Product COMMITTED TO A MAKING DIFFERENCE Specified Professions Liability Product SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION This is an application for a claims made policy. Please read your policy

More information

THE MEDICAL PROTECTIVE COMPANY MULTI-SPECIALTY HEALTHCARE PROFESSIONAL PROFESSIONAL LIABILITY INSURANCE APPLICATION

THE MEDICAL PROTECTIVE COMPANY MULTI-SPECIALTY HEALTHCARE PROFESSIONAL PROFESSIONAL LIABILITY INSURANCE APPLICATION APPLICATION INSTRUCTIONS If previously covered with Medical Protective, or joining a current Medical Protective Healthcare Professional group policy, please enter the Policy Number: THE MEDICAL PROTECTIVE

More information

Dental Corporation Professional Liability Insurance Application

Dental Corporation Professional Liability Insurance Application With your fully completed, signed and dated application, you must submit the following information: 1. Current insurance policy declarations page. 2. Copy of extended reporting endorsement (tail) from

More information

Personal Lines Insurance Agents Professional Liability

Personal Lines Insurance Agents Professional Liability COMMITTED TO A MAKING DIFFERENCE Personal Lines Insurance Agents Professional Liability INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION All questions must be answered and application must

More information

Personal Lines Insurance Agents Professional Liability

Personal Lines Insurance Agents Professional Liability Personal Lines Insurance Agents Professional Liability PART I - AGENCY DETAILS P.O. Box 2909 Jacksonville, FL 32203-2909 Phone: 800-342-2498 Fax: 904-355-7611 www.shellyins.com INSURANCE AGENTS AND BROKERS

More information

DENTISTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis)

DENTISTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) DENTISTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) APPLICANT S INSTRUCTIONS: 1. Answer all questions. If the answer requires detail, please attach a separate sheet. 2. Application must be signed

More information

Property Managers Professional Package Product

Property Managers Professional Package Product COMMITTED TO A MAKING DIFFERENCE Property Managers Professional Package Product PROPERTY MANAGERS PROFESSIONAL PACKAGE PRODUCT APPLICATION All questions must be answered and application must be signed

More information

Travelers 1 st Choice REAL ESTATE SERVICES PROFESSIONAL LIABILITY COVERAGE APPLICATION

Travelers 1 st Choice REAL ESTATE SERVICES PROFESSIONAL LIABILITY COVERAGE APPLICATION Travelers 1 st Choice REAL ESTATE SERVICES PROFESSIONAL LIABILITY COVERAGE APPLICATION Travelers Casualty and Surety Company of America Hartford, Connecticut IMPORTANT NOTE: This is an application for

More information

Real Estate Claims-Made Professional Liability Insurance Application

Real Estate Claims-Made Professional Liability Insurance Application Real Estate Claims-Made Professional Liability Insurance Application Application completion instructions. PLEASE DO NOT USE PENCIL Answer each question completely. If the question does not apply, print

More information

Temporary (Locum Tenens) Request for Malpractice Insurance

Temporary (Locum Tenens) Request for Malpractice Insurance Insurance Company Temporary (Locum Tenens) Request for Malpractice Insurance In order for temporary (locum tenens) coverage to apply under this policy, the following conditions must exist: The Insured

More information

List all Prior Insurers for the last 10 years include all places of employment: (attach separate list if necessary) Carrier or Self-

List all Prior Insurers for the last 10 years include all places of employment: (attach separate list if necessary) Carrier or Self- Applicant's : of Corporation, Partnership or Association Coverage Requested: Occurrence Claims-Made Requested Effective : Coverage period if less than 1 year: From: To: Requested retroactive date: (Coverage

More information

Catlin Underwriting Agency, U.S., Inc. 1330 Post Oak Blvd. Ste 2325 Houston, TX 77056

Catlin Underwriting Agency, U.S., Inc. 1330 Post Oak Blvd. Ste 2325 Houston, TX 77056 Catlin Underwriting Agency, U.S., Inc. 1330 Post Oak Blvd. Ste 2325 Houston, TX 77056 CORPORATE EMERGENCY ROOM / AMBULATORY CARE MEDICAL PROFESSIONAL UNDERWRITING QUESTIONNAIRE AND APPLICATION FOR PROFESSIONAL

More information

Greenwich Insurance Company

Greenwich Insurance Company REAL ESTATE PROFESSIONAL ERRORS AND OMISSIONS INSURANCE APPLICATION tice: This is an application for a policy that contains Claims-made liability protection. Coverage for prior acts and claims made after

More information

Ancillary Professional Liability Renewal Application

Ancillary Professional Liability Renewal Application A. Applicant Information Name of Applicant (First, Middle, Last) Applicant s Business Address (Street, City, State, Zip Code) Ancillary Professional Liability Renewal Application Business Phone: Fax: E-mail:

More information

Eidyia Insurance Services

Eidyia Insurance Services Eidyia Insurance Services MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE AND REPORTED BASIS. NOTICE: THE LIMIT OF LIABILITY AVAILABLE TO

More information

Select coverage's interested in: Professional Health Business (Liability / Property) Commercial Auto Personal (Auto / Home) Other

Select coverage's interested in: Professional Health Business (Liability / Property) Commercial Auto Personal (Auto / Home) Other Application / Quote Form Cover Page Request Requested Effective Date: Radigan Insurance & Associates - PO Box 71399 Phoenix AZ 85050 O: 866-576-0977 F: 877-576-0101 E: Service@RadiganInsurance.com W: www.radiganinsurance.com

More information

Personal Lines Insurance Agents Professional Liability

Personal Lines Insurance Agents Professional Liability USLI.COM 888-523-5545 Personal Lines Insurance Agents Professional Liability INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION All questions must be answered and application must be signed

More information

1. Name of applicant Last First Middle. Complete title of your medical professional designation. 12:01 AM E.S.T. on Month Day Year

1. Name of applicant Last First Middle. Complete title of your medical professional designation. 12:01 AM E.S.T. on Month Day Year 2 Park Avenue 8 British American Blvd. New York, NY 10016 Latham, NY 12110 Tel: 212-576-9800 Tel: 518-786-2700 2 Clinton Square 90 Merrick Avenue Syracuse, NY 13202 East Meadow, NY 11554 Tel:315-428-1188

More information

PLICO, Inc. Application Guideline

PLICO, Inc. Application Guideline PLICO, Inc. Application Guideline Thank you for your consideration of PLICO for your professional liability insurance needs. Since 1979, PLICO has been the leading choice by Oklahoma physicians for protecting

More information

GENERAL INFORMATION. Telephone Number: Fax Number: Email Address: Web Address:

GENERAL INFORMATION. Telephone Number: Fax Number: Email Address: Web Address: 1 st Choice Real Estate Services Professional Liability Coverage Application SM Travelers Casualty and Surety Company of America THE INFORMATION BEING REQUESTED IS FOR A CLAIMS MADE POLICY. IT IS IMPORTANT

More information

Chiropractor Professional Liability Application

Chiropractor Professional Liability Application Chiropractor Professional Liability Application 746 Alexander Road, Princeton, NJ 08540-6305 (800) 334-0588 www.princetoninsurance.com Chiropractor Professional Liability Application Section I General

More information

DISABILITY CLAIM FORM

DISABILITY CLAIM FORM ACE American Insurance Company PROOF OF LOSS Mail to: ACE American Insurance Company Name of Group: UNIVERSITY OF CALIFORNIA P.O. Box 15417 Wilmington, DE 19850 800-336-0627 or 302-476-6194 Policy Number:

More information

INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION

INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION NOTICE: The insurance coverage for which you are applying is written on a claims-made and reported policy form. Subject to policy provisions,

More information

COURT REPORTERS ERRORS AND OMISSIONS INSURANCE APPLICATION CLAIMS MADE POLICY

COURT REPORTERS ERRORS AND OMISSIONS INSURANCE APPLICATION CLAIMS MADE POLICY United National Insurance Company United National Specialty Insurance Company Penn-Star Insurance Company A Stock Company Bala Cynwyd, PA Administrative Offices: Three Bala Plaza East, Suite 300 Bala Cynwyd,

More information

ANALYTICAL TESTING LABORATORY ERRORS AND OMISSIONS INSURANCE APPLICATION CLAIMS MADE POLICY

ANALYTICAL TESTING LABORATORY ERRORS AND OMISSIONS INSURANCE APPLICATION CLAIMS MADE POLICY United National Insurance Company United National Specialty Insurance Company Penn-Star Insurance Company A Stock Company Bala Cynwyd, PA Administrative Offices: Three Bala Plaza East, Suite 300 Bala Cynwyd,

More information

Ambulatory surgery centers Application form

Ambulatory surgery centers Application form Applicant information 1. Applicant name: 2. Principal business address (attach separate sheet if more than one location): 3. Telephone: 4. Website: 5. Date established: 6. Applicant s practice is a: solo

More information

231 South Bemiston, Suite 1000 St. Louis, MO 63105 Email: submissions@galeninsurance.com

231 South Bemiston, Suite 1000 St. Louis, MO 63105 Email: submissions@galeninsurance.com 231 South Bemiston, Suite 1000 St. Louis, MO 63105 Email: submissions@galeninsurance.com LOCUM TENENS NEW BUSINESS APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE CLAIMS MADE COVERAGE INFORMATION REQUIRED

More information

OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application

OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application OneBeacon Insurance Company Lawyers Professional Liability Moonlighting Legal Services Application NOTICE: This is an application for a claims-made and reported policy. Subject to its terms, this policy

More information

LAWYERS PROFESSIONAL LIABILITY NEW BUSINESS APPLICATION

LAWYERS PROFESSIONAL LIABILITY NEW BUSINESS APPLICATION ASPEN AMERICAN INSURANCE COMPANY LAWYERS PROFESSIONAL LIABILITY NEW BUSINESS APPLICATION NOTICE: This is an application for a claims-made and reported policy. Coverage for prior acts and claims made after

More information

JEWELRY APPRAISERS ERRORS AND OMISSIONS INSURANCE APPLICATION CLAIMS MADE POLICY

JEWELRY APPRAISERS ERRORS AND OMISSIONS INSURANCE APPLICATION CLAIMS MADE POLICY United National Insurance Company United National Specialty Insurance Company Penn-Star Insurance Company A Stock Company Bala Cynwyd, PA Administrative Offices: Three Bala Plaza East, Suite 300 Bala Cynwyd,

More information

TWIN CITY FIRE INSURANCE COMPANY Name of Insurance Company to which Application is made NEW YORK ACCOUNTANTS PROFESSIONAL LIABILITY APPLICATION

TWIN CITY FIRE INSURANCE COMPANY Name of Insurance Company to which Application is made NEW YORK ACCOUNTANTS PROFESSIONAL LIABILITY APPLICATION TWIN CITY FIRE INSURANCE COMPANY Name of Insurance Company to which Application is made NEW YORK ACCOUNTANTS PROFESSIONAL LIABILITY APPLICATION NOTICE: THIS IS A CLAIMS-MADE POLICY. THE COVERAGE OF THIS

More information

MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION

MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION THIS IS AN APPLICATION FOR CLAIMS-MADE AND REPORTED INSURANCE PROVIDED THROUGH HORIZON RISK INSURANCE, LLC. IT IS IMPORTANT

More information

AUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING USE (BOBTAIL)

AUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING USE (BOBTAIL) National Casualty Company Home Office: Madison, Wisconsin Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza

More information

APPLICATION FOR NURSE ANESTHETISTS PROFESSIONAL LIABILITY INSURANCE

APPLICATION FOR NURSE ANESTHETISTS PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR NURSE ANESTHETISTS PROFESSIONAL LIABILITY INSURANCE NOTICE: The policy for which application is made provides coverage on a CLAIMS MADE basis. Please read the policy carefully. If space

More information

Ambulance Services, Medical Transport Mainform Application

Ambulance Services, Medical Transport Mainform Application Applicant Information 1. Applicant name: 2. Principal business address (attach separate sheet if more than one location): 3. Telephone number: 4. Date established: 5. Applicant s practice is a: Solo practitioner

More information

PROFESSIONAL LIABILITY INSURANCE ADD LAWYER INFORMATION SUPPLEMENT

PROFESSIONAL LIABILITY INSURANCE ADD LAWYER INFORMATION SUPPLEMENT PROFESSIONAL LIABILITY INSURANCE ADD LAWYER INFORMATION SUPPLEMENT Medmarc Casualty Insurance Company 14280 Park Meadow Drive Suite 300 Chantilly, VA 20151-2219 800.356.6886 703.652.1300 1. New Lawyer:

More information

GREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Liability Insurance Application

GREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Liability Insurance Application GREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Liability Insurance Application NOTICE: This is an application for a Claims-Made policy. Coverage for prior acts and claims made after termination

More information

REAL ESTATE RELATED ERRORS & OMISSIONS APPLICATION

REAL ESTATE RELATED ERRORS & OMISSIONS APPLICATION Kinsale Insurance Company P. O. Box 17008 Richmond, VA 23226 (804) 289-1300 www.kinsaleins.com REAL ESTATE RELATED ERRORS & OMISSIONS APPLICATION APPLICANT S INFORMATION 1. Legal name of the business who

More information

In completing this application, please be sure to completely answer all questions and to do the following:

In completing this application, please be sure to completely answer all questions and to do the following: We appreciate your interest in and hope you will soon join our family of members. We ask you to complete and return the enclosed application. Please provide the information requested below. If you are

More information

Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application

Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application NOTICE: This is an application for a Claims-made policy. Coverage for prior acts and claims made after

More information

REQUESTED COVERAGE ADOPTION AGENCY AND FOSTER PLACEMENT

REQUESTED COVERAGE ADOPTION AGENCY AND FOSTER PLACEMENT REQUESTED COVERAGE ADOPTION AGENCY AND FOSTER PLACEMENT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,500,000 Requesting Professional Liability: Requested Retro Date: Professional

More information

PHYSICIAN PROFESSIONAL LIABILITY INSURANCE ENTITY APPLICATION

PHYSICIAN PROFESSIONAL LIABILITY INSURANCE ENTITY APPLICATION PHYSICIAN PROFESSIONAL LIABILITY INSURANCE ENTITY APPLICATION All questions must be answered completely If the answer to any question is NONE or NOT APPLICABLE, so state Upon receiving a copy of your final

More information

Corporate Healthcare Professional Liability Application

Corporate Healthcare Professional Liability Application Corporate Healthcare Professional Liability Application Requested Effective Date Required Documents In addition to this application, the following information is required: 1. Loss runs, dated within 60

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO

More information

Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE SMALL ACCOUNTING FIRM APPLICATION

Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE SMALL ACCOUNTING FIRM APPLICATION Travelers 1 st Choice ACCOUNTANTS PROFESSIONAL LIABILITY COVERAGE SMALL ACCOUNTING FIRM APPLICATION SM Travelers Casualty and Surety Company of America Hartford, Connecticut Important Note: This is an

More information

Insurance Agents and Brokers Professional Liability

Insurance Agents and Brokers Professional Liability Insurance Agents and Brokers Professional Liability Quaker Special Risk P.O. Box 1350 Eatontown, NJ 07724 Phone: 800 447-4180 Fax: 732 223 9072 INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION

More information

CONSULTANTS ERRORS AND OMISSIONS INSURANCE APPLICATION CLAIMS MADE POLICY

CONSULTANTS ERRORS AND OMISSIONS INSURANCE APPLICATION CLAIMS MADE POLICY United National Insurance Company United National Specialty Insurance Company Penn-Star Insurance Company A Stock Company Bala Cynwyd, PA Administrative Offices: Three Bala Plaza East, Suite 300 Bala Cynwyd,

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO

More information

HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION

HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR

More information

DENTISTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis)

DENTISTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) DENTISTS PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) APPLICANT S INSTRUCTIONS: 1. Answer all questions. If the answer requires detail, please attach a separate sheet. 2. Application must be signed

More information

Professional Risk Facilities,

Professional Risk Facilities, P R F Professional Risk Facilities, MISCELLANEOUS PROFESSIONAL LIABILITY ERRORS & OMISSIONS APPLICATION NOTICE: THIS IS AN APPLICATION FOR A CLAIMS-MADE AND REPORTED POLICY WHICH, SUBJECT TO ITS PROVISIONS,

More information

Legal Name of Applicant Website Tax ID Number

Legal Name of Applicant Website Tax ID Number 500 Virginia St. E. Ste 1200 Tel: 304.343.3000 Charleston, WV 25301 Toll-Free: 888.998.7642 P.O. Box 3697 Fax: 304.342.0985 Charleston, WV 25336-3697 www.wvmic.com Agency Address Producer Agent Information

More information

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION

MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION 610-668-7100 MPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY

More information

Real Estate Errors and Omissions Insurance Application NEW YORK

Real Estate Errors and Omissions Insurance Application NEW YORK Real Estate Errors and Omissions Insurance Application NEW YORK THIS IS A CLAIMS-MADE POLICY. THE LIMITS OF LIABILITY OF THIS POLICY CAN BE REDUCED, AN MAY BE COMPLETELY EXHAUSTED, BY CLAIMS EXPENSES.

More information

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY APPLICATION FOR TEACHING PERMIT Chapter 466.002, Florida Statutes Rule 64B5-7.005, Florida Administrative Code Applications will be accepted only if completed

More information

PROFESSIONAL LIABILTY APPLICATION

PROFESSIONAL LIABILTY APPLICATION DIRECTIONS: 1. Complete the application (all pages) in full by filling in the blue fields. 2. Please fill in all the fields with the correct information. 3. Email the application to apps@cossioinsurance.com

More information

POST MORTEM SERVICES Supplemental Application

POST MORTEM SERVICES Supplemental Application POST MORTEM SERVICES Supplemental Application Rockwood Programs, Inc. 3001 Philadelphia Pike Claymont, DE 19703 Tel: 800-365-0816 Fax: 302-764-9125 sales@rockwoodinsurance.com This is an application for

More information

APPLICATION FOR NURSE ANESTHETISTS PROFESSIONAL LIABILITY INSURANCE

APPLICATION FOR NURSE ANESTHETISTS PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR NURSE ANESTHETISTS PROFESSIONAL LIABILITY INSURANCE NOTICE: The policy for which application is made provides coverage on a CLAIMS MADE basis. Please read the policy carefully. If space

More information

APPLICATION FOR INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY

APPLICATION FOR INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY Home Office: One Nationwide Plaza Columbus, Ohio 43215 Administrative Office: 8877 rth Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 APPLICATION FOR INSURANCE AGENTS AND BROKERS PROFESSIONAL

More information