Follow the steps to complete your application with ease.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in the agent information section with the appropriate details, including the agent's name, address, phone, fax, email, and website.
3. Indicate which coverage program you are applying for by checking one of the boxes: Per-Patient Visit Program, RVUs Program, or Medical Group Program.
4. Attach the required documents as indicated, including the curriculum vitae for healthcare professionals, copies of professional liability policies, and your loss runs from the past six years if applicable.
5. Complete the general information section by providing the name of the Emergency Medical Group, tax ID number, mailing address, email address, and authorized representative for insurance matters.
6. List the names and addresses of the hospitals where the Emergency Medical Group practices, including identifying the levels of emergency care provided.
7. In the miscellaneous section, carefully answer questions regarding your practice and previous insurance history, providing detailed information when necessary.
8. For the staff section, list all physicians and non-physician staff currently employed by the Emergency Medical Group, including their specialties and hours worked per week.
9. Detail your previous insurance carriers and the limits of liability desired, ensuring you indicate whether the coverage was claims-made or occurrence-based.
10. Complete the retroactive coverage section if applicable, indicating any intent to purchase extended reporting endorsements and providing necessary claims history.
11. If you answered yes to question 14, complete the claim information section with details about each claim.
12. Finally, review all completed sections for accuracy, save your changes, and proceed to download, print, or share the completed form.

Begin your application now to ensure your Emergency Medical Group receives the necessary insurance coverage.