Get Kammco 102a 2020-2026

This guide provides step-by-step instructions on how to accurately complete the KAMMCO 102A application for claims-made professional liability insurance for non-physician healthcare professionals. Filling out this form is crucial for securing your coverage, so it is important to pay close attention to each section and provide complete information.

Follow the steps to successfully complete the KAMMCO 102A application.

1. Click the ‘Get Form’ button to obtain the KAMMCO 102A application and open it in the form editor.
2. In Section A, fill out the applicant information. Begin with your name, including first, middle, and last names. Then, select your gender and provide your business address, contact numbers, and email address.
3. Still in Section A, provide your date of birth and social security number, along with your home address. Please note that a P.O. Box is not accepted as a valid address.
4. In Section B, specify your professional occupation from the provided list. If your occupation is not listed, select 'Other' and fill in the appropriate title.
5. In Section C, answer the questions concerning requested coverage, including the existing form of insurance, policy details for the past five years, limits of liability, and requested retroactive date.
6. In Section E, detail your education and training, including the highest level of education and the school of graduation. Also, indicate whether you hold the required certification or licensure.
7. Section F asks for practice information. Specify any independent contractor work, the hours you work per week, and any ownership in a professional corporation or association.
8. In Section G, carefully answer underwriting questions, noting any situations that could affect your application, such as insurance status or disciplinary actions.
9. Section H requires you to provide information regarding any claims or suits made against you in relation to your professional services, along with a completed claim information worksheet if necessary.
10. Conclude by filling out Section I for comments and explanations for any previous sections, then sign and date the application at the bottom.
11. Once completed, save your changes, download the application if necessary, and submit it via email or fax to the provided contact.

Start filling out your KAMMCO 102A application online today for comprehensive professional liability coverage.