Get Kammco 102a 2018

Filling out the KAMMCO 102A is an essential step for non-physician healthcare professionals seeking claims-made professional liability insurance. This guide provides clear and detailed instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the KAMMCO 102A form online effectively.

1. Click the ‘Get Form’ button to obtain the KAMMCO 102A form and open it for editing.
2. Begin by filling out the applicant information section. Provide your agency name (if applicable), first, middle, and last name, gender, business address, employer, and contact information in the specified fields.
3. In the professional occupation section, specify your occupation by selecting from the provided list. Ensure that you check the required fields related to Kansas Health Care Stabilization Fund participation if applicable.
4. For current coverage, indicate existing insurance forms and provide details about your insurance carrier, policy number, coverage dates, and limits for the past five years.
5. In the requested coverage section, select the limits of liability appropriate for your practice and input the requested retroactive date.
6. Complete the education, training, and work experience section. Provide details about your highest education level, school of graduation, certifications, and licensing information.
7. Answer the underwriting questions honestly and provide explanations for any 'yes' responses in the comments section if needed.
8. Fill out the claim information section, including any existing claims by providing the necessary details as prompted.
9. Review all sections for completeness and accuracy. Make sure that your signature and the date are filled out where indicated.
10. Finally, save your changes, download the completed form, and submit it via email to underwriting@kammco.com or fax to 785.232.4704.

Start filling out the KAMMCO 102A form online today for your professional liability insurance needs.