Follow the steps to successfully complete your application online.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin filling out the applicant organization’s name and any legal entities that require coverage. Ensure to include past and present names.
3. Answer whether you wish to change your current insurance structure. This question is essential for your application.
4. Indicate if any of the listed events occurred in the last 12 months or are planned for the next 12 months. Provide details in a separate letterhead if you answer 'Yes' to any questions listed, including changes in operations, locations, contracts, or services.
5. Respond to the query regarding the requirement for physicians and independent licensed practitioners to carry professional liability insurance. Detail the accreditation status of the applicant if applicable.
6. Report the gross revenue for the current and projected year. Ensure projections are for the next 12 months.
7. Complete the professional services section by providing projected numbers for visits or beds for various health services. This detail is crucial for the rating.
8. Answer whether the applicant is involved in Complementary and Alternative Medicine and if they house patients overnight.
9. Respond to questions regarding staffing changes, including any changes to medical directors or licensed practitioners.
10. Provide updated loss history for the past 5 years, along with required details regarding incidents.
11. Finally, review all provided information, then ensure the form is signed and dated by an authorized officer, completing the submission process.

Complete your application online today to ensure a smooth and efficient review process.