Locum Tenens Malpractice

Locum Tenens Malpractice
* Required Information

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First name:*
Last name:*
Address 1
Address 2
City:
State:
Zip code:*
Phone numbers:	Daytime:*
	Evening:
	Fax:
E-Mail address:*
Office Contact Person
Name of Healthcare provider you are covering for:
Requested dates of coverage
Area of Specialty:
Which States are you licensed in?
Do you preform surgical procedures/	Yes No
If yes (select all that apply)	In Office Sugery Center Hospital
Are you:	Board Certified Board Eligible Neither

Current Insurance Company
Current Limits of Liability	Each Claim
	Aggregate
Desired Limits of Liability	Each Claim
	Aggregate
Last Annual Premium:
Requested Effective Date:
Current Coverage:	Claims Made* Occurrence
*Retroactive Date:
Have you ever been involved in a claim?	Yes No
Number of Open Claims
Number of Closed Claims
Amount Paid or Settled?
If Yes, please give dates and status:

Please contact me at a future date:
I would prefer to be contacted:	via email via telephone via fax in the mail
How did you hear about us?

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