Get Application For Chiropractors Professional Liability Insurance

Completing the Application For Chiropractors Professional Liability Insurance online is an essential step in securing coverage for your practice. This guide will provide you with a clear and supportive approach to accurately fill out each section of the application, ensuring you provide all necessary information.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing your applicant information. This includes entering your full name along with any degree designations, your principal business address, and telephone numbers for both home and office.
3. Fill out the personal information section. Be sure to include your Social Security number, chiropractic license number(s), the state(s) you are licensed in, and the expiration date of your license.
4. Indicate whether you are licensed to practice any additional health care practices, providing details as necessary. Specify your education by including the name of your chiropractic college, city, state, and the year you graduated.
5. Select your requested limits of liability by checking the applicable box that corresponds with your coverage preference.
6. Respond to the question about your status as a covered entity under the HIPAA Privacy Rule and provide the name and title of your privacy officer if applicable.
7. Detail your practice experience since graduation and describe your current practice type. You may want to attach additional sheets as necessary.
8. Report the number of hours per week that you practice and estimate the annual patient visits you handle.
9. Indicate any anticipated changes in your practice within the next 12 months.
10. Outline the procedures or devices you use in your practice, checking 'Yes' or 'No' for each listed procedure.
11. Complete questions related to your procedures, such as whether you use acupuncture, prescribe drugs, or perform any specific treatments.
12. Fill out any operational details, including whether you use a collection agency, engage in advertising, or maintain professional relationships.
13. Provide information on your staff, indicating the number of different roles employed in your practice.
14. Lastly, answer queries regarding your professional history or claims. Attach additional explanations for any 'Yes' responses.
15. Once all sections are completed, review your application for accuracy before signing and dating the form.
16. Save changes, download, print, or share your completed form as needed.

Take action today and complete your application online to ensure your chiropractic practice is adequately protected.