Page 1 of 2 A75 (09/03)
Application For Nurse Professional Liability
1. Name of Applicant
Street
Address
City
State Zip
Applicant’s Web Site Address
2. Degree of Certification:
CNP RN LPN PA
Year Conferred
Institution
If CNP or PA, describe duties
*
3. Are you an:
Employee Independent Contractor
4. Indicate the percent of time spent in the following work locations:
% Administrative office % Outpatient clinic % Classroom
% Laboratory % Hospital ER % Patient’s Home
% Professional office % Nursing Home % OR
% Hospital Ward % Abortion Clinic % Other
5. Do you administer any an
esthesia?
Yes No
6. Do you administer IV or Chemotherapy?
Yes No
If so, describe any special training
.*
7. Do you provide OB/GYN or Midwife services?
Yes No
If yes, describe.
*
8. Has your nursing licens
e ever been suspended or revoked?
Yes No
If yes, give details
.*
9. Prior insurance carrier and loss history last 5 years. If no prior insurance, check here.
Year Insurance Company
Policy
Number
Loss paid/
reserved
Description
10. Is the applicant, aware of a
ny circumstances that may result in a claim?
Yes No
If yes, provide details.
*
Member Companies of Western World Insurance Group
Western World Insurance Company
Tudor Insurance Company
Stratford Insurance Company
