ALLIED HEALTHCARE PROFESSIONAL LIABILITY APPLICATION

 

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  • POSITIVE PHYSICIANS INSURANCE EXCHANGE



    850 CASSATT ROAD 100 BERWYN PARK SUITE 220 BERWYN, PA 19312

    Phone: 888-335-5335 Fax: 610-644-5265

    ALLIED HEALTHCARE PROFESSIONAL LIABILITY APPLICATION




    Please answer all questions in full. If a question does not apply to your practice, state “none” or “N/A” (Not Applicable). Please indicate any additional responses on the Remarks Section.

    The complete application, together with any supplementary information, must be signed and dated by the applicant in all spaces indicated. Failure to provide complete information will delay the processing of the application.
  • I. General Information

  • StateExpirationLicense #Temporary StatusPermanent Status 
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  • Please list all office locations where you currently practice. Use the Remarks Section to list additional locations at which you render professional services.
  • List where have you practiced your profession for the past 10 years other than your current practice locations. Please explain any gaps in your practice. Use the Remarks Section to list additional locations. Do not list training locations.

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