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Address 2

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County Where You Practice
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Name of Your Corporation
 
Is coverage for your corporation desired?
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Present Insurance Company

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Specialty of Practice
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Type of Policy
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Retroactive Date (claims-made only)
 
Hours per week
 
RENEWAL DATE OF POLICY
 
Have you ever had a malpractice suit?
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If Yes, how many in the last 10 years?
 
How many claims are still open?
 
How many have been closed with an indemnity payment?

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Medical License Number
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