Get Form 2713r5

Filling out Form 2713r5 online can be a straightforward process when you follow the right steps. This guide provides clear and detailed instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the Form 2713r5 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the surcharge amounts in the designated fields as applicable for your situation.
3. Fill in the cancellation section, including any details related to the return surcharge and additional surcharge, if applicable.
4. Provide the effective date in the specified format. Ensure that the dates are accurate for the coverage period.
5. Indicate the reason for any surcharge changes by filling in the reason in the provided field.
6. Input the health care provider's name and medical license number. If operating under a 'doing business as' name, include all relevant names in a list.
7. Enter your email address for the Patient's Compensation Fund enrollment confirmation, and provide the entity's EIN or license number.
8. Fill in the address fields, ensuring the street, city, state, and zip code are accurate.
9. Complete the policy number field and choose the type of coverage: occurrence or claims made.
10. Specify the retro date and whether employees are included in the coverage.
11. Indicate the coverage dates by providing the start and end dates.
12. Detail the limits of liability for both per occurrence and annual aggregate amounts.
13. Record the date the surcharge was received from the provider, along with any premium details.
14. If applicable, fill in details regarding various credits available for health care providers as specified in the form.
15. Provide the name of the insurance carrier and the contact information of the person completing the form.
16. Verify all information is accurate, and proceed to finalize the document.
17. Save changes, and then download, print, or share the completed form as needed.

Complete your Form 2713r5 online today to ensure timely processing of your application.