Inspirien Allied Healthcare Entity Application

APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE FOR ALLIED HEALTHCARE PROVIDERS

CLAIMS MADE - ENTITY

Throughout this application, where sufficient space is unavailable for a complete answer, please attach a separate sheet, referencing the question(s) being answered, signed and dated at the bottom.

Year Outstanding	Number of Claims	Total Paid	Total Reserves

Accident Date	Description	Total Paid	Total Reserves Outstanding

APPLICATIONS

APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE FOR ALLIED HEALTHCARE PROVIDERS

CLAIMS MADE - ENTITY

Step 1 of 9

A. General Data

B. Outpatient Utilization of Facilities and Services Offered by or Under Jurisdiction of Your Facility: Projected for Current Year.

C. Other Services Offered by or Under Jurisdiction of the Facility:

D. Professional Personnel – Employed and Contracted. Show the number of persons and full time equivalents (FTE) based on 40 hour work week.

E. Residency Programs or Training Schools

F. Anesthesia Services

G. Physician Services/Emergency Room

H. Credentialing Policy (Physician)

I. Physical Plant

J. Total Area

K. Current Information

L. Limits of Coverage Requested

M. Liability Loss Experience (Past 5 Years)