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Medical Professional Liability Insurance Form

Stage 1/4
PHYSICIANS , SURGEONS , DENTISTS , AND PODIATRISTS
This application is for claims-made coverage. It is subject to review and acceptance by The Company and does not bind coverage. Additional information may be requested by The Company.
Requesting Addition to a Current NORCAL Mutual Policy
If accepted, coverage will be extended only while you are acting within the course and scope of your duties for the group and will be subject to the terms, conditions, and limitations of the policy. A copy of the policy will be made available to you upon request.
APPLICATION CHECKLIST
Section i: general INFORMATION
GENERAL INFORMATION
Medical Licensure
Section II: Coverage INFORMATION
Coverage Desired
Please provide a copy of your current Declarations page from your most recent Insurance Carrier, as well as copies of any extended reported endorsements (tails) that you may have purchased.
Will you also carry insurance with another company ?
If yes, please explain in the Remarks Section.
Coverage History
List all previous medical professional liability insurance you have had for the past 5 years, beginning with the most current.