Application for Group Physician Policy

Step 1 of 2

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  • Please print responses in ink, and answer all questions in full. If a questions does not apply to your practice, state “none” or “N/A” (Not Applicable). Please indicate any additional responses. This application consists of A) application(s) for insurance, including any additional pages and Claim information form. 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



  • Primary Address/Location



  • List other Practice Addresses: (attach letterhead if necessary)




  • Billing Address Other than Primary Practice


    If you require that your premium billing be sent to an address other than your primary practice address, please indicate.



  • II GROUP COVERAGE

  • (you must attach a copy of the most recent Declarations Page from your present carrier indicating the original effective date of coverage.)



  • III PHYSICIANS


    Please identify all physicians for whom you seek coverage. A separate application should be completed for each physician in addition to this application.

    NAME/TITLE ---- LICENSE NUMBER --- SPECIALTY --- RETROACTIVE DATE

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