Name of Applicant
Mailing Address
Contact Person
Phone #
Fax #
E-mail Address
To:
(current or previous insurer)
Dear Sir or Madam:
I request and authorize
(current or previous insurer) to release all professional liability claims, both actual and potential, made against me while I was insured by a policy of their company, to
Birtwhistle & Livingston, 71 East Palisade Avenue, Englewood, NJ 07631
, or its agent, employees or representatives. I agree to indemnify and hold
(current or previous insurer) harmless of any liability, expense or claims arising out of the release of this information.
Name
Date
Policy #
Social Security #
Medical License #
Note:
This form, or a duplicate of it, must be submitted for each insurer you have had over the last five (5) years.