Get Rockbridge Physician Application - Healthcare Professional ...

Completing the Rockbridge Physician Application is a crucial step for healthcare professionals seeking professional liability insurance for multi-practice clinics or large group practices. This guide provides clear and comprehensive instructions on how to fill out each section of the application accurately.

Follow the steps to complete your application effectively.

1. Click ‘Get Form’ button to access the application and open it in your digital document editor.
2. Begin with the General Information section. Fill in your full name, tax identification number, location address, city, state, zip code, county, mailing address, website address, telephone number, and facsimile number. Ensure all information is accurate and up-to-date.
3. Move to the section for legal entities. List the names and descriptions of all legal entities to be insured, including entity type and any applicable prior acts date.
4. In the Coverage Requested section, specify the effective date, retroactive date, deductibles, and the limits of desired coverage. Indicate whether you are purchasing tail coverage if applicable.
5. Provide details regarding your previous professional liability insurance coverage for the past three years, including policy numbers, levels of liability, and any claims made.
6. Complete the Operations section. Detail the patient mix and average annual patient load, along with other operational details such as patient services provided.
7. Fill in the Loss Control section by answering questions regarding your clinic's safety programs, agreements, and procedures for maintaining quality and safety.
8. Complete the Claims Information section. If any claims have been made against you, document them clearly and provide requested details to maintain transparency.
9. Review all information filled in the application for accuracy. Make sure to address any fields marked with N/A if applicable.
10. Once the application is complete, you can save changes, download a copy for your records, print the form or share it as needed.

Submit your completed application online to ensure you have the necessary professional liability insurance coverage.