Get Physician Application - Ismie.com

Filling out the Physician Application is an essential step for obtaining professional liability insurance. This guide provides clear, detailed instructions to help users navigate the application efficiently and correctly.

Follow the steps to complete your application with ease.

1. Press the 'Get Form' button to access the Physician Application and open it for editing.
2. Start by filling in your personal details in the designated fields such as your name, title, and date of birth. Make sure to provide all required information. Check for any shaded areas which should remain blank.
3. Provide the desired effective date of coverage and retroactive date for prior acts coverage in the appropriate fields, ensuring accurate date formats.
4. Complete the sections regarding your medical licenses, including the medical license number, controlled substance number, and attach copies of relevant licenses as instructed.
5. Enter your home address, email, and contact details accurately to ensure all correspondence reaches you.
6. Document your previous insurance carriers for the last ten years and ensure you have current loss history from each listed carrier.
7. Follow the prompts to report your practice details, including medical specialties and board certifications, and provide additional training history if applicable.
8. Fill out the sections related to your practice relationships, hospital privileges, and any cosmetic or major risk procedures you perform.
9. Review and complete the applicant's representation section carefully, ensuring that you sign and date the application.
10. Once all sections are completed, you can save your changes, download the application for your records, and print or share it as necessary.

Complete your Physician Application online today to ensure your professional liability coverage is in place.