Physical Therapy Facility Application

Physical Therapy Facility Application

  • Please enter a value between 9 and 9.
  • Please attach schedule(s) below
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  • Past 12 MonthsProjected Next 12 Months 
  • Past 12 MonthsProjected Next 12 Months 
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  • Past 12 MonthsProjected Next 12 Months 
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  • describe other type of organization and ownership
  • NameRelationship 
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    If yes, please provide the name and relationship
  • Member, Partner, or Stockholder?Employed by Organization?Position? 
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    If yes, complete Appendix A, - Staff schedule of this application
    If yes, attach a copy of insurance company’s loss run(s)
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    This section must be completed by all applicants. All of the above information is true to the best of my knowledge and belief. I understand that signing this application does not bind Positive Physicians Insurance Exchange to complete the insurance, but it is agreed that this application shall be the basis of contract should a policy be issued. I authorize release and exchange of any underwriting or claims information between all prior carriers and Positive Physicians Insurance Exchange. I understand that Positive Physicians Insurance Exchange reserves the right to reject any applicant that does not meet its underwriting standards.
  • Appendix A – Staff Schedule

  • NameLicense #Specialty / PositionDate of HireEmployee / Independent ContractorAvg # of hrs worked per week 
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  • NameLicense #Specialty / PositionDate of HireEmployee / Independent ContractorAvg # of hrs worked per week 
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  • NamePositionDate of HireAvg # of hrs per week 
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