Medical Malpractice Inquiry

Name: *

Entity Type:

Group Name or Entity: *

Desired Coverage Effective Date: *

Month

Day

Year

Business Address Line 1:

Business Address Line 2:

City:

State:

Zip Code:

Contact Name: *

Business Phone Number: *

Cell Phone Number:

E-mail Address:

Preferred Contact Method:

Entity Retroactive Date:

Month

Day

Year

Federal Employee Identification Number (FEIN #):

Current Insurance Company: *

Policy Expiration Date: *

Month

Day

Year

Current Premium:

Current Agent:

Has any physician been investigated by a State Licensing Board, DEA or any other governmental regulatory agency?

Yes

No

Does any physician have Medical Directorship Responsibilities?

Yes

No

Does any physician visit nursing homes on a regular basis?

Yes

No

If the answer to the any of the above questions is yes, please describe:

Has any physician practiced medicine previously in a state other than Virginia?

Yes

No

If the answer to the above question is yes, please select which state(s)?

If so, was a Reporting Endorsement (Tail Insurance) purchased for the out of state exposure?

Yes

No

For OB Physicians - number of physicians participating in the Birth Injury Fund

Please list all physicians in Birth Injury Fund

Have there been any claims to current policy? *

Yes

No

If there have been claims, please provide brief description

Additional information / comments you would like to tell us:

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