| 6. MALPRACTICE INSURANCE |
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| A. MALPRACTICE INSURANCE |
| List below your current malpractice carrier. Upload a copy of your current policy certificate and/or declarations page indicating you as the covered clinician, and showing the coverage limits and dates of coverage. If you are unable to upload this document, please fax to 866-612-7795. |
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| If you have not possessed coverage with the same carrier for the past 5 years, list below the name and complete address of any other malpractice carrier who has provided coverage for you for the most recent five (5) year period. If there has been more than one carrier, please indicate the dates of coverage with each carrier, and the reason for changing carriers. |
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Carrier |
Policy |
Effective |
Expired |
Limits |
Delete |
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| Please provide information on pending and/or settled malpractice claims. |
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| B. MALPRACTICE CLAIMS |
| Be as specific as possible with regard to procedures, names, dates, and actions. Explanations provided on pending and/or settled malpractice claims must include the minimum information requested below. |
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| Use the Add Claim button to document any additional occurrences and additional claims. |
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| C. MALPRACTICE DOCUMENTS |
| Documentation is required if you have malpractice claims pending or settled in the past five (5) years (include any settlements/adjudications, original complaint and final disposition). The documentation must be from an attorney or the entity that issued the judgment. If you are unable to upload this document, please fax to 866-612-7795. |
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