Please attach schedule(s) below
describe other type of organization and ownership
If yes, please provide the name and relationship
If yes, complete Appendix A, - Staff schedule of this application
If yes, attach a copy of insurance company’s loss run(s)
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