Page 2 of 2 A43 (10/05)
15. List name and specialization of M.D.(s), including insurance coverage:
NAME LIMITS POLICY # CARRIER EXPIRATION
1.
2.
3.
4.
5.
Are all M.D.(s) gra
duates of USA Schools?
Yes No
Are all M.D.(s) board certified eligible?
Yes No
16. Does clinic perform services other than abortions and related counseling?
Yes No
Describe
17. Do any do
ctors have claims pending or paid as respects their personal
Yes No
practice during last five (5) years? If so, describe each claim.
18. Doe
s the clinic or any employee have a claim pending or a claim settled
Yes No
that occurred during last five (5) years? If so, describe each claim.
Ha
s any carrier cancelled, declined or refused to renew professional liability insurance?
Yes No
If so, provide details.
19. LIMITS OF INSURANCE REQUESTE
D:
General Aggregate Limit (Other than Products-Completed
Operations)
$
Products – Completed Operations Aggregate Limit $
Personal and Advertising Injury $
any one person or
organization
Each Occurrence Limit $
Damage to Premises Rented to You (up to $50,000 limit available) $
any one premise
Medical Expense Limit (up to $5,000 limit available) $
any one person
Each Professional Incident Limit (If applicable) $
Effective Dates Desired: From _
___________ To ____________
Applicant’s Signature:
Date:
Ti
tle:
Producing Agent:
