Commonwealth of Massachusetts Board of Registration in Medicine 200 Harvard Mill Square, Suite 330 Wakefield, MA 01880 Telephone: (781) 8768210 Fax: (781) 8768383 www.mass.gov/massmedboardLIABILITY.
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How to fill out the MA Liability Carrier Request Form online
This guide will help you effectively complete the MA Liability Carrier Request Form online. By following these straightforward instructions, you can ensure that your application process is efficient and meets all necessary requirements.
Follow the steps to successfully complete the form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In the first section, print your name clearly where indicated as 'Applicant Print Name.' This identifies you as the person submitting the request.
- Next, you will need to list all liability carriers you have been covered by for the past 10 years. Make sure to include only those from the time you held a full license in the U.S. or Canada. If your postgraduate training occurred in that time frame, include those carriers as well.
- For each liability carrier, provide the dates of coverage. Enter the 'From' and 'To' dates in the designated fields.
- Enter the policy number associated with each liability carrier in the specified fields, ensuring this information is accurate and complete.
- If you have additional liability carriers, repeat the previous two steps until all relevant information is documented.
- Once all fields are filled out, review the information for accuracy before finalizing.
- After verifying the information, save your changes. You can then download, print, or share the completed form as needed.
Complete your documents online today for a smooth application process.
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