Get Pli Form (resignation) - Texas Tech University Health Sciences ...

Filling out the PLI Form (Resignation) at Texas Tech University Health Sciences is a straightforward process. This guide provides step-by-step instructions to help you accurately complete the form online, ensuring your resignation request is processed efficiently.

Follow the steps to fill out the PLI Form (Resignation) accurately.

1. Begin by clicking the ‘Get Form’ button to download the PLI Form (Resignation) and open it in your preferred editor.
2. Type or print your date of resignation in the provided 'DATE' field at the top of the form.
3. In the 'ACTION REQUESTED' section, select the 'Resignation' option by marking the checkbox next to it.
4. Fill out your personal information in the designated fields, including your last name, first name, middle name, and social security number.
5. Specify your gender by marking the appropriate checkbox.
6. Indicate your professional title by selecting 'M.D.', 'D.O.', or 'D.D.S.' in the mandatory section.
7. Enter your Texas license number, DPS number, DEA number, and institutional permit number in the respective fields.
8. Complete the location field by checking the appropriate box for Amarillo, El Paso, Lubbock, Odessa, or Prison/Health Care Systems.
9. If applicable, fill out the 'NEW DEPARTMENT' if you are transitioning to a different one.
10. Provide your effective resignation date and new risk class, if any, in the relevant fields.
11. Complete the signature section by signing and dating the form as the insured, and ensure your department chair does the same.
12. Once all fields are complete, save your changes, download the form, and print it if necessary. Ensure you keep a copy for your records.
13. Submit the completed form along with any required documentation to the Office of General Counsel, Professional Liability Division at Texas Tech University Health Sciences.

Start filling out your documents online today to ensure a smooth resignation process.