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PAJUA.com Website: http://www.pajua.com APPLICATION FOR HOSPITAL PROFESSIONAL LIABILITY INSURANCE Limits of Liability: $500,000 Per Occurrence / $2,500,000 Per Annual Aggregate POLICIES ARE ISSUED ON AN ANNUAL BASIS UNLESS OTHERWISE SPECIFIED AND APPROVED BY THE JUA COVERAGE CANNOT BEGIN PRIOR TO APPLICATION AND PREMIUM RECEIPT BY THE JUA JUA Coverage, if issued, will be on a CLAIMS-MADE Basis Requested Effective Date: Requested Retroactive Date: PART I GENERAL INFORMATION Applicant.

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