New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625
(609) 826-7100
Malpractice Insurance Verication Form
____________________________________________ has applied for a medical license with the State of New
of New Jersey. He/she held medical malpractice insurance issued by your company. Please complete this form,
attach relevant supporting documentation concerning any medical malpractice cases in which this practitioner
was named and the business card of the individual completing this form and return directly to:
State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625
Malpractice Insurance Company Name:___________________________________________________________
Address: _____________________________________________________________________________________
Street City State Zip Code Country
Dates of coverage: from:___________________ to ____________________
Month / Dsy / Year Month / Dsy / Year
Dates should include entire period the insured was covered, not just the dates of the current policy.
List the name(s) and status of each case in which the doctor has been involved. Attach supporting
documents concerning the status of the case.
Plaintiff’s Name Status
______________________________________________ ________________________________
______________________________________________ ________________________________
______________________________________________ ________________________________
______________________________________________ ________________________________
1. Was this doctor ever denied malpractice coverage? Yes No
2. Was this doctor’s practice ever curtailed or limited? Yes No
3. Was this doctor ever assessed a surcharge based upon specic claims history? Yes No
4. Was ofce monitoring or special hospital monitoring ever required for this doctor? Yes No
5. Was this doctor ever subjected to underwriting review based upon specic claims history or for any other
cause? Yes No
__________________________________________________________ _____________________________
Print Name and Title of the person completing this form. Date
__________________________________________________________
Signature of the person completing this form.
BME-MI-17
Insured’s Name
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signature
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