| *Required Information |
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| First Name * : | |
| Last Name * : | |
| Street Address * : | |
| City * : | State * Zip * |
| Phone Number * : | |
| Email Address * : | |
| Date of Birth * : | |
| Professional State License Number * : | |
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1. Has your licensed ever been suspended or revoked? Have you ever been the subject of an ethics investigation by a state or professional licensing agency?
Yes No
If yes please attach a separate document with your explanation |
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2. Have you ever been treated for substance abuse?
Yes No
If yes please attach a separate document with your explanation |
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3. Have you ever had a claim made against you or do you currently have reason to believe a claim might be made against you?
Yes No
If yes please attach a separate document with your explanation |
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4. Has your professional liability insurance ever been cancelled or non-renewed?
Yes No
If yes please attach a separate document with your explanation |
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| I am a/an |
| Aide | Licensed Practical Nurse |
| Licensed Vocational Nurse | Registered Nurse |
| Certified Nurse Specialist | Physicians Assistant |
| Nurse Practitioner/Advanced Practice Nurse | Certified Nurse Assistant |
| Nurse Midwife | Nurse Anesthetist |
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| If you are a Registered Nurse or a Certified Nurse Specialist which area do you primarily work in? |
| Obstetrics First Assist Other |
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| If you are a Physicians Assistant, Nurse Practitioner, or an Advanced Practice Nurse which area do you primarily work in? |
| Obstetrics/Womens Health Psychiatry Pediatrics Surgical Other |
| Family Planning/Gyn Aesthetics Family Geriatrics Acute/Critical Care |
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If you are a Nurse Midwife
Do you work under the auspices of an Obstetrician who carries Professional Liability Limits of at least $250,000/$750,000? OR Is your Obstetrician board certified with hospital privileges?
Yes No
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Do you deliver exclusively in a hospital or other institutional setting?
Yes No
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Are you ACNM Certified?
Yes No
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| Policy and Coverage Information |
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| 1. What coverage do you desire? | Claims Made Occurrence |
| 2. What limits do you desire? | $100,000/$300,000 $250,000/$750,000 Other Limits |
| 3. Desired policy effective date? | |
| 4. Do you currently have professional liability coverage? | Yes No |
| 5. If you do have coverage what is the expiration date of the policy? | |
| 6. If you currently have professional liability coverage is it: | Claims Made Occurrence |
| 7. If your current coverage is Claims Made what is the retro date of the policy? | |
| 8. For Claims Made expiring coverage, do you want prior acts coverage? | Yes No |
| 9. How many hours a week do you work in a medical professional capacity? | |
| 10. Are any of these hours covered by other insurance? | Yes No How many? |
| 11. Are you a member of any association or organization? | Yes No Which ones? |
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| NOTICE TO APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE." |
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| The electronic signature will be held with the two pieces of information listed below. |
| Eye Color | Mother Maiden Name |
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I understand that by checking the box below that I am attesting that I have read the Subscription Agreement and Investor letter.
I Agree |
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