Washington Healthcare Insurance Company,

A Risk Retention Group (WHI)

9229 Sierra College Boulevard

Roseville, CA 95661-5919

Main: (916) 773-3992 Fax: (916) 773-8208

APPLICATION

DENTIST PROFESSIONAL LIABILITY

CLAIMS MADE POLICY

Idaho Healthcare Insurance

A Risk Retention Group (IHI)

9229 Sierra College Boulevard

Roseville, CA 95661-5919

Main: (916) 773-3992 Fax: (916) 773-8208

APPLICATION

DENTIST PROFESSIONAL LIABILITY

CLAIMS MADE POLICY

Oregon Healthcare Insurance Company,

A Risk Retention Group (OHI)

9229 Sierra College Boulevard

Roseville, CA 95661-5919

Main: (916) 773-3992 Fax: (916) 773-8208

APPLICATION

DENTIST PROFESSIONAL LIABILITY

CLAIMS MADE POLICY

NOTICE

THIS IS AN APPLICATION FOR AN INSURANCE POLICY TO BE ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE FOR YOUR RISK RETENTION GROUP.

WASHINGTON HEALTHCARE INSURANCE COMPANY, A RISK RETENTION GROUP IS A DBA: OF CALIFORNIA HEALTHCARE INSURANCE COMPANY, INC., A RISK RETENTION GROUP

THE STATEMENT AND REPRESENTATIONS MADE HEREIN BY THE APPLICANT ARE WARRANTED TO BE TRUE AND COMPLETE, AND IT IS UNDERSTOOD THAT IF A POLICY OF INSURANCE IS ISSUED, IT WILL BE ISSUED IN RELIANCE UPON THE TRUTH OF SUCH REPRESENTATIONS AND THAT THIS APPLICATION WILL FORM A PART OF THE POLICY ISSUED.

NOTICE

IDAHO HEALTHCARE INSURANCE, A RISK RETENTION GROUP IS A DBA: OF CALIFORNIA HEALTHCARE INSURANCE COMPANY, INC., A RISK RETENTION GROUP

NOTICE

OREGON HEALTHCARE INSURANCE COMPANY, A RISK RETENTION GROUP IS A DBA: OF CALIFORNIA HEALTHCARE INSURANCE COMPANY, INC., A RISK RETENTION GROUP

General Information:

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you practice at more than one location? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How many locations do you practice from? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Enter each Practice Address and Percentage at each location (total % must equal 100%) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Mailing Address if different from above {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Main Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Confirm Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Fax {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Office Manager or Main Contact {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policy Information:

Policy Period {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Limit of Liability requested {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you applying for prior acts coverage? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, requested Retroactive Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Attach a copy of your current Declarations Page {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Are you entering practice for the first time? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you had coverage for the past 5 Years {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurance Carrier {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Effective Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Expiration Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Claims-made or Occurrence {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Limits {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

PROFESSIONAL INFORMATION:

Dental School Attended {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Year of Graduation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Did you complete a residency? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES” Month/Year Completed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

List all active professional licenses (State, Type, and License number) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Are you a member of any state Dental Association/Society? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you taken a Risk Management Seminar in the past three (3) years? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of attendance {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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YOUR PRACTICE:

Do you own the practice? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Under which business structure do you practice? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name of Employer/Facility: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please provide explanation as to how you qualify as an independent contractor: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Does your practice operate under a different name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

List all entities you own or have ownership in, including DBAs and trade names: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

If you have a legal entity, do you need coverage for the entity? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is the sole function/purpose of this entity for the practice of dentistry? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please provide the number of the following who work for you:

Employee dentist (other than yourself and/or partners/corporate officers): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Independent contractor dentists: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other dentists sharing facilities with you: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

All other employees (hygienists, assistants, technicians, clerical, etc.): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How many hours do you work per week? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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How many patients do you see per week, including hygiene? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

SPECIALTY:

Indicate your Practice Specialty (please check all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

PROCEDURES PERFORMED IN YOUR PRACTICE:

Which of the following procedures are performed by you or by someone under your supervision/ direction (includes other dentists):

Sleep Apnea Therapy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, please indicate the following {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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“Sargenti”, paste fill for formaldehyde based endodontic techniques excluding formocresol primary tooth pulpotomies. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Irreversible TMJ-Phase II (such as crown and bridge, Occlusal equilibration, surgery, orthodontics undertaken primarily to treat a TMJ disorder). {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Implant Surgery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Extraction of Impacted Teeth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Implant Restoration {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Molar Endodontics on Permanent Teeth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Ozone Therapy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Neuralgia-inducing Cavitational Osteonecrosis (NICO) lesion surgery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Neuromuscular Dentistry {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

NONE OF THE ABOVE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If "Yes" to any question above, please describe {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you treat or prescribe medication for any of the following:

Smoking and/or Tobacco Cessation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Prolotherapy, Platelet Rich Plasma or PRP {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Weight Loss Therapy (i.e. wiring of the jaw, etc.) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you are a general Dentist doing specialty procedures:

How many dental referrals do you receive annually? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

For what procedures? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Who refers the patients to you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What procedures do you refer to others? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do all patients complete a written dental/medical history form? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How often do your patients complete a written updated health history form? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you consistently use informed consent? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Which procedures do you use a specific informed consent form that the patient signs? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you consistently use informed refusal of treatment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you offer 24 hour emergency care for patients not currently under your care? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you perform cosmetic dermal procedures (including but not limited to Botox, Restylane, collagen injections, UL Therapy, etc.)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, please describe {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Does anyone employed by you perform cosmetic dermal procedures? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you offering any new procedures and/or services? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, please describe {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

ANESTHETICS AND ANALGESIA:

Are you practicing sedation dentistry? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If Yes, what levels do you provide?: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If administering general anesthesia/deep sedation in your office who administers the anesthesia? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does the Dentist, MD Anesthesiologist or CRNA carry their own professional liability insurance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you met the basic education, including continuing education requirements, appropriate for all levels of sedation you provide, including BLS, ACLS and PALS, as required by law? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Attach copies of all permits you have for sedation. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

DENTAL LABORATORY/DENTAL IMAGING SERVICES

Do you operate a dental laboratory? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, do you accept referrals for other than your patients? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, is there a separate business entity/corporation for this purpose? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you utilize any advanced CT imaging scans in your diagnosis and treatment planning? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you operate any advanced CT imaging equipment? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you own the equipment? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is the equipment used on patients other than your own? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, is there a separate entity/corporation for this purpose? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are the results read by a Radiologist? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you provide radiology services for other than your patients or on a referral basis? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

LICENSE AND CLAIMS HISTORY

Do you have hospital privileges? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, please describe {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Has any governmental agency, including a state licensing board, ever taken action against either your dental and/or narcotics license including suspension, revocation, probation, restriction, denial or other sanctions? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, provide a copy of the board transcript or other documentation, including resolution {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Have you been under investigation or currently under investigation by any governmental agency including a state licensing board or other regulatory agency? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, provide a copy of the board transcript or other documentation, including resolution. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Have you been convicted of any criminal charges? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, please explain {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Have you ever had any professional liability insurance refused, cancelled or non-renewed? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, please explain {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Has any claim or suit alleging malpractice ever been brought against you or your entity? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If "Yes" please complete Attachment A

Are you currently aware of any situation that could lead to a malpractice suit against you or your entity? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, please describe {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

INSURANCE HISTORY

Do you have an active Professional Liability policy to cover a practice location for which you are not requesting coverage? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Was an extended reporting endorsement (tail) purchased from your previous carrier? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you are applying for prior acts coverage, was your practice during the period for which you are requesting prior acts coverage different in any way from your current practice? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If “YES”, please explain {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

EMPLOYMENT PRACTICES LIABILITY (EPL)

An Employment Practices Liabilty (EPL) sub-limit of $25k is included with your WHI professional liabilty insurance coverage. If you wish to waive the EPL coverage, please click below. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Number of employees: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Total Number of Full Time Employees: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Total Number of Part Time Employees: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Percentage of employees that are union employees: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Employee turnover rate, in the last 18 months: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Top 3 causes of employee turnover: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Have you undergone (last 12 months) or are you planning to undergo (next 12 months) any type of company restructuring that may lead to employee layoffs, early retirements or reassignment of duties? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you involved in all hirings, promotions, terminations and demotions? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have a written Human Resources policy/procedure manual? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of last review and by whom? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Entire manual reviewed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Select policies/procedure reviewed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you currently have the following in place (check all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you contact legal counsel for consultation in the event of a termination? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

CERTIFICATION OF INFORMATION PROVIDED

I, the undersigned, hereby declare that all answers and statements herein given are true and complete to the best of my knowledge and I have not omitted or withheld any fact or circumstance, which would be relied upon in the determination by the insurance company indicated on this application in granting liability insurance. I understand that this application, and any documents provided are made part of the policy that is issued.

I authorize any state board examiners or licensers, hospital board or committee, insurance company, professional society, past or present business or medical associate or private person that may have any record or knowledge concerning any of the answers or statements made herein to release such information to the insurance company or its assigns. I authorize the use of a copy of this acknowledgement in lieu of its original.

I understand that my Professional Liability insurance will be written on a “Claims-Made form” and acknowledge that this coverage will only respond to claims which are reported during the term of this policy. I also acknowledge that my “Claims-Made” coverage will not provide insurance coverage for claims which occurred prior to the “”Prior Acts Date” of my policy.

I understand that, should my “Claims-Made” policy with this insurance company ever be cancelled or non-renewed, for reasons other than non-payment of the premium, or if I decide to terminate the policy for any other reasons, I can elect to purchase an Extended Reporting Period (“Tail”) Endorsement subject to the policy terms and conditions. An Extended Reporting Period Endorsement provides protection for any claims which may have occurred during the term of the “Claims-Made” policy, but were not reported to the insurance company before the date of the policy termination.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How did you hear about us {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

FRAUD NOTICE – WHERE APPLICABLE UNDER THE LAW OF YOUR STATE

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. (For Oregon only: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing materially false or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, may commit a fraudulent insurance act, which may be a crime and may be subject to civil fines and criminal penalties.) (For Washington, Idaho and Tennessee residents only: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.) (For Arizona residents only: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.)

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

ATTACHMENT A SUPPLEMENT TO APPLICATION CLAIM / SUIT REPORT

Please complete one Attachment A for each claim or suit alleging malpractice that was brought against you. Answer in adequate detail to allow proper evaluation. Attach copies of patient’s charts, operative notes or other documents as appropriate.

Name of patient {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Claim or Suit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of incident {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Location of incident {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Allegation: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Condition/diagnosis at time of incident: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Dates/description of treatment rendered: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Your insurance carrier: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Disposition of claim or suit: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Settlement Against {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

$ {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Judgment/verdict Against {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

$ {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I understand this information is part of my Professional Liability Insurance Application.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

DO YOU NEED ANOTHER ATTACHMENT A SUPPLEMENT TO APPLICATION CLAIM / SUIT REPORT {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

ATTACHMENT A SUPPLEMENT TO APPLICATION CLAIM / SUIT REPORT

Name of patient {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Claim or Suit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of incident {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Location of incident {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Allegation: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Condition/diagnosis at time of incident: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Dates/description of treatment rendered: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Your insurance carrier: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Disposition of claim or suit: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Settlement Against {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

$ {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Judgment/verdict Against {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

$ {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I understand this information is part of my Professional Liability Insurance Application.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you are not re-directed to a page that says “Thank you for filling out the form. You will receive an e-mail shortly” then please scroll through your application to check for required fields that are not completed. Required fields are highlighted in red.