1. I need coverage for the following (Please mark all that apply):
2. Do You Have Full-Time, Primary Employment?Yes No
3. Do you have secondary sources of income aside from that listed above? Yes No
4. Have you ever been convicted of a crime?Yes No
5. Have you had any liability losses exceeding $5,000 within the last five years?Yes No
6. Are you a medical professional?Yes No
a. Indicate whether you will exclusively perform:Surgery Minor Surgery No Surgery Medical Mission Other
b. Have you had any claim for professional negligence, including any demand for money from an attorney or patient or been named in any lawsuit?Yes No
c. Have you had any action of any kind with your professional license from any governing body?Yes No
d. How many patients do you anticipate seeing in the next 12 months? 0 - 500 500 - 1,000 1,000 - 1,500 1,500 - 2,000 2,000 - 2,500 2,500 - 3,000 3,000 - 3,500 3,500 - 4,000 4,000 - 4,500 4,500 - 5,000 5,000 - 5,500 5,500 - 6,000 6,000 - 6,500 6,500 - 7,000 7,000 - 7,500 7,500 - 8,000 8,000 - 8,500 8,500 - 9,000 9,000 - 9,500 9,500 - 10,000 10,000 - 10,500 10,500 - 11,000 11,000 - 11,500 11,500 - 12,000 12,000 - 12,500 12,500 - 13,000 13,000 - 13,500 13,500 - 14,000 14,000 - 14,500 14,500 - 15,000 15,000 - 15,500 15,500 - 16,000 16,000 - 16,500 16,500 - 17,000 17,000 - 17,500 17,500 - 18,000 18,000 - 18,500 18,500 - 19,000 19,000 - 19,500 19,500 - 20,000 More than 20,000
e. How much revenue do you anticipate receiving for your activities within the next 12 months? $0.00 - $2,500.00 $2,500.00 - $5,000.00 $5,000.00 - $7,500.00 $7,500.00 - $10,000.00 $10,000.00 - $12,500.00 $12,500.00 - $15,000.00 $15,000.00 - $17,500.00 $17,500.00 - $20,000.00 $20,000.00 - $22,500.00 $22,500.00 - $25,000.00 $25,000.00 - $27,500.00 $27,500.00 - $30,000.00 $30,000.00 - $32,500.00 $32,500.00 - $35,000.00 $35,000.00 - $37,500.00 $37,500.00 - $40,000.00 $40,000.00 - $42,500.00 $42,500.00 - $45,000.00 $45,000.00 - $47,500.00 $47,500.00 - $50,000.00 $50,000.00 - $52,500.00 $52,500.00 - $55,000.00 $55,000.00 - $57,500.00 $57,500.00 - $60,000.00
f. Please provide your license info:
License #: Issuing state: Expiration:
g. Will you be doing any alternative/complementary medicine or performing any off-label use of any modality or substance?Yes No
h. Do you have liability insurance for your primary employment? Yes No
Name of insurer Limits Effective Dates Retroactive Dates Premium
7. Do you own a small business?
Yes No
a.Do you have any employees, other than family members in clerical positions? Yes No
Yes No
