Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to download the application form. Make sure to open it in a compatible browser to avoid any display issues.
2. Begin by filling in your name. Include your last name, first name, and middle name as requested.
3. Input your date of birth in the specified format: Month, Day, Year.
4. Provide your mailing address, ensuring to include the number and street, city or county, state, and zip code.
5. Specify your principal office address and, if applicable, an additional office address.
6. Indicate the basis on which you wish to have your policy issued, such as Claims Made or Occurrence.
7. Select the desired limits of liability from the options provided.
8. Complete the required fields detailing your practice, including percentages of patient hours spent across different counties and states.
9. Answer questions regarding any prior criminal convictions or medical license restrictions, providing details as necessary.
10. Fill in your social security number, telephone numbers, fax number, and email address.
11. Indicate the effective date of the insurance you wish to apply for.
12. Respond to additional questions regarding risk management courses and prior insurance coverage, including specifics about your previous insurance policies.
13. Detail your educational history, including medical schools attended and any internships, residencies, or fellowships completed.
14. List your current hospital appointments and other professional affiliations.
15. Complete any sections regarding claim history, providing specific details for each claim or suit if applicable.
16. Review all entered information for accuracy, then save your changes. You will have the option to download, print, or share the completed form.

Complete your application online today to secure your professional liability insurance!