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APPLICATION FOR CLINICS MEDICAL DENTAL PUBLIC HEALTH MENTAL HEALTH OTHER PROFESSIONAL LIABILITY INSURANCE NOTICE The policy for which application is made provides coverage on a CLAIMS MADE basis. Please read the policy carefully. If space is insufficient to answer any question fully attach a separate sheet. I. GENERAL INFORMATION a Full name of Applicant b Principal practice address Street State City c Location Stand alone d e Zip i Phone ii E-Ma.

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