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| Caution: It is not the intention of the Insurance Company to cover any incident, circumstance, act, error or omission of which you are currently aware, which may be expected to result in a claim or suit. Prior Acts coverage is subject to Company approval and all questions must be answered. |
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1. Name of Applicant |
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2. Name of Prior Carrier
(Please mail a copy of your most recent policy, including all endorsements.) |
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3. Retroactive Date used by your Prior Carrier |
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4. List all locations where you have practiced or taught in the last ten (10) years.
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| 5. In the past ten (10) years, have you practiced as a (check all that apply): |
| sole |
| employed physician |
| professional association/corporation |
| partnership |
| independent contractor |
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| Is PA/PC Prior Acts coverage desired? Yes No |
| If so, was your PA/PC covered for Prior Act previously? Yes No |
| If so, please mail a copy of dec page/endorsement evidencing Prior Acts coverage for the PA/PC, the name of the PA/PC, and all the members of the PA/PC. |
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6. In what specialties have you practiced since the retroactive date you have requested?
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| 7. Have you changed, added or deleted any aspects of your practice in the last ten years? Yes No |
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If yes, please describe and indicate dates:
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| 8. Has coverage been continuously in force since the retroactive date you are requesting? Yes No |
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| 9. Any incident, circumstance, act, error or omission, even a request for records, of which you are aware, should be reported to your current carrier. Describe all such known incidents below. |
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