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Home
/ Medical Malpractice Inquiry
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Medical Malpractice Inquiry
Name:
*
Entity Type:
Select
Solo
Corporation
Partnership
Group Name or Entity:
*
Desired Coverage Effective Date:
*
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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:
Select
Phone
E-mail
Entity Retroactive Date:
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Federal Employee Identification Number (FEIN #):
Current Insurance Company:
*
Policy Expiration Date:
*
Month
Month
Jan
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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)?
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
