Section VII - Professional Liability Insurance

Please include the insurance companies you have had in the last 10 years, BEGINNING WITH YOUR INTERNSHIP, who have provided professional liability coverage. If you require additional space, please use a separate document and upload:

ANY GAP IN CHRONOLOGY REQUIRES EXPLANATION ON A SEPARATE PAGE:

Current Insurance Carrier
Prior Insurance Carrier

If the answer is ''YES'' to any of the following questions, please explain in the text area or upload a separate document.

General Questions

Have you ever practiced medicine without liability coverage?

Have you ever been denied professional liability insurance or has your policy ever been cancelled or denied renewal?

Have any restrictions ever been placed on your liability insurance?

Have you ever had an insurance carrier add a surcharge to your malpractice policy or increase your deductible?

If the answer is ''YES'' to any of the following questions, please complete a Malpractice Claims/Suit History (in the Claims History Section) for each event.

Have you ever received a notice of claim* or been a defendant in a medical malpractice suit rising out of or in connection with your individual professional services?

*Notice of claim is defined as a written communication from a claimant or plaintiff setting forth an allegation of professional malpractice, threatening or initiating legal action, and demanding money damages.

Are you aware of any such notice of claims against another person or entity rising out of or in connection with your individual professional services?

Have you or your malpractice carrier or any other person or entity made an out-of-court settlement or paid a judgement on a professional liability claim on your behalf or on behalf of any other person or entity rising out of or in connection with your individual professional services in the past 10 years?

Progress List