Birtwhistle & Livingston: Appendix C


Name of Organization
Tax ID#		Retroactive date of insurance
Description of operations performed


	Past 12 Months:	Projected next 12 Months:
Patient visits (each encounter):
Gross receipts:
Payroll:
Other:

Are there overnight facilities available? Yes No
Hours of Operation

Has the organization ever been sued regardless of whether the claim was dismissed on a judgement rendered? Yes No
(If yes, please complete the Supplemental Claims Information form)

Name of current professional liability carrier
(Please mail a copy of the declarations page showing: retro date, limits of liability, policy period and restrictive endorsements)

Has your professional liability insurance ever been cancelled, refused or non-renewed? Yes No

Are procedures in place for patient transfers to another facility in the event of an emergency? Yes No
If yes, please describe:


Are medications administered? Yes No
If yes, by whom?


Are there subsidiaries that are to be included in this coverage? Yes No
If yes, please list names of subsidiaries and mail a current organizational chart.


Please complete a copy of this appendix for each organization named.