Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935 Ship To: 4822 Madison Yards Way
Madison, WI 53708-893
5 Madison, WI 53705
FAX #: (608) 251-3036 E-Mail: dsps@wisconsin.gov
Phone #: (608) 266-2112 Website: http://dsps.wi.gov
DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING
MALPRACTICE SUITS OR CLAIMS FORM
This form must be completed in its entirety by the licensure applicant.
APPLICANT INFORMATION: (required)
Name of Applicant:
Application ID# Number:
(if applicable)
AFFIDAVIT OF APPLICANT:
I declare that I am the person referred to on this application and that all answers set forth are each and all strictly true in every
respect. I understand that failure to provide requested information, making any materially false statement and/or giving any
materially false information in connection with my application for a credential, or for renewal or reinstatement of a credential,
may result in credential application processing delays; denial, revocation, suspension, or limitation of my credential; or any
combination thereof; or such other penalties as may be provided by law. I further understand that if I am issued a credential, or
renewal or reinstatement thereof, failure to comply with the statutes and/or administrative code provisions of the licensing
authority will be cause for disciplinary action.
Applicant Signature:
/ /
List all malpractice suits, claims, or settlements in which you were involved. Provide a brief description of the allegations and final
disposition. For any malpractice suits resolved within the past ten (10) years, provide copies of claims/suits, final settlements,
dispositions, or dismissed information. (Continue on page two and/or attach additional sheets if necessary.)
Parties:
Date
Filed:
/ /
/ /
Court and Case No.
ition:
Description of Legal Action or Claim:
#282
9 (Rev. 7/18)
Wis. Stat. ch. 448 Page 1 of 2
Committed to Equal Opportunity in Employment and Licensing
(Print and Sign Form)
