Get Il Sm-30003 2005-2025

Filling out the IL SM-30003 form is an essential step for obtaining professional liability insurance for medical laboratories, medical imaging centers, and blood plasmapheresis centers. This guide will provide you with clear, step-by-step instructions to help you complete the form accurately.

Follow the steps to successfully complete the IL SM-30003 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your general information. Provide the full name of the applicant, the principal business premise address, and the secondary locations if applicable. Be sure to include your contact information such as phone, fax, email address, and website.
3. Indicate the number of employees, specifying whether they are full-time, part-time, or seasonal. Then, provide the date of organization and total square footage occupied by your facility.
4. Select the type of applicant from the provided options (individual, corporation, limited liability company, etc.) and indicate if your laboratory or center is mobile or stationary.
5. List the states in which the applicant is licensed to practice and answer whether the applicant is a 'Covered Entity' under HIPAA. If yes, provide details about compliance and the name of the Privacy Officer.
6. In the operations section, describe the nature of your operations, services, and procedures offered. Attach additional materials if necessary.
7. Provide information about drug testing, laboratory approvals, and the annual gross receipts, along with an estimation of future gross receipts.
8. Complete the section on professional activities by percentages related to various services provided, and indicate whether services are open to the public or involve any specific medical practices.
9. In the staff section, input the total number of professional employees and differentiate by profession. Indicate if coverage is requested for employed and/or contracted physicians.
10. Finally, review the claims history section, answering questions about previous claims, disciplinary actions, and past insurance coverage. Provide all necessary context, including details of any incidents.
11. Once you have filled out all segments of the form, you can save your changes, download the completed form, print it, or share it as required.

Complete your application online today to ensure your coverage for your medical services.