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CONTACT INFORMATION
Name
Phone
Email
Address
Fax
City
State
Zip
PRACTICE INFORMATION
Primary Area of Practice
No Surgery
Minor Surgery
Major Surgery
Secondary Area of Practice
No Surgery
Minor Surgery
Major Surgery
Full Time or Part Time
Full Time
Part Time Practice
If Part Time Number Of Hours
If Part Time The Year You Started Part Time
TYPE OF PRACTICE
Sole Practitioner
Yes
No
Group
Yes
No
If You Answered Yes On Group Practice How Many Are In Your Group?
Part of a Corporation
Yes
No
If You Are a Part Of a Corporation What is the legal name of that Corporation
PERCENT OF PRACTICE
Home Visits Percent
Assisted Living Visits Percent
Nursing Home Visits Percent
Office Visits Percent
Other (describe) Percent
CURRENT POLICY INFORMATION
Current Insurer
Policy Expiration Date
Retroactive date (if claims made)
Number of years without a paid claim or notice of intent
1-5
6-10
11-20
Limit of Liability:
$100,000/$300,000
$200,000/$600,000
$250,000/$750,000
$500,000/$1.5MM
$1MM/$3MM
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