Section C: Professional Liability Insurance
Please provide information on all professional liability insurance carriers from whom youhave received coverage in the past 10 years.
Current Professional Liability Insurance:
Carrier:
Address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Policy Number:
Original Effective Date:
/
Month
/
Day
Year
Date
Expiration Date:
/
Month
/
Day
Year
Date
Per Occurrence $:
Aggregate $:
Retroactive Date:
/
Month
/
Day
Year
Date
What type of coverage do you have?
Claims Made
Occurrence
Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage?
Yes
No
Please upload a copy of your policy:
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of
Do you have a previous professional liability insurance to enter?
Yes
No
Previous Professional Liability Insurance:
Carrier:
Address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Policy Number:
Original Effective Date:
/
Month
/
Day
Year
Date
Expiration Date:
/
Month
/
Day
Year
Date
Per Occurrence $:
Aggregate $:
Retroactive Date:
/
Month
/
Day
Year
Date
What type of coverage do you have?
Claims Made
Occurrence
Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage?
Yes
No
Do you have a previous professional liability insurance to enter?
Yes
No
Previous Professional Liability Insurance:
Carrier:
Address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Policy Number:
Original Effective Date:
/
Month
/
Day
Year
Date
Expiration Date:
/
Month
/
Day
Year
Date
Per Occurrence $:
Aggregate $:
Retroactive Date:
/
Month
/
Day
Year
Date
What type of coverage do you have?
Claims Made
Occurrence
Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage?
Yes
No
Do you have a previous professional liability insurance to enter?
Yes
No
Previous Professional Liability Insurance:
Carrier:
Address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Policy Number:
Original Effective Date:
/
Month
/
Day
Year
Date
Expiration Date:
/
Month
/
Day
Year
Date
Per Occurrence $:
Aggregate $:
Retroactive Date:
/
Month
/
Day
Year
Date
What type of coverage do you have?
Claims Made
Occurrence
Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage?
Yes
No
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Next
Section D:
Education and Training
Medical/Professional School:
Institution Name:
Mailing Address:
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Degree:
Year Graduated:
Dates attended: (From)
/
Month
/
Day
Year
Dates attended: (To)
/
Month
/
Day
Year
If you are a graduate of a foreign medical school, are you certified by the Educational Commission for Foreign Medical Graduates (ECFMG)?
Yes
No
Date Issued:
/
Month
/
Day
Year
Serial Number for ECFMG:
Were you the subject of any disciplinary action during your attendance at this institution?
Yes
No
Please attach an explanation since you have selected yes.
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of
Did you have more than one medical/professional school?
Yes
No
Please attach additional information that duplicates the information requested above:
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of
Do you have an Internship to enter:
Yes
No
Internship:
Institution Name:
Department Chair or Program Director:
First Name
Last Name
Department Chair or Program Director Degree:
Mailing Address:
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Dates attended: (From)
/
Month
/
Day
Year
Dates attended: (To)
/
Month
/
Day
Year
Type of internship:
Rotating
Straight
If straight, please list specialty:
Did you successfully complete this program?
Yes
No
Please attach an explanation since you have selected no.
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of
Were you the subject of any disciplinary action during your attendance at this institution?
Yes
No
Please attach an explanation since you have selected yes.
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of
Did you have more than one internship?
Yes
No
Please attach additional information that duplicates the information requested above:
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of
Do you have an residency to enter:
Yes
No
First Residency:
Institution Name:
Department Chair or Program Director:
First Name
Last Name
Department Chair or Program Director Degree:
Mailing Address:
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Dates attended: (From)
/
Month
/
Day
Year
Dates attended: (To)
/
Month
/
Day
Year
Type of residency:
Did you successfully complete this program?
Yes
No
Please attach an explanation since you have selected no.
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of
Were you the subject of any disciplinary action during your attendance at this institution?
Yes
No
Please attach an explanation since you have selected yes.
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Cancel
of
Do you have an second residency to enter:
Yes
No
Second Residency:
Institution Name:
Department Chair or Program Director:
First Name
Last Name
Department Chair or Program Director Degree:
Mailing Address:
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Dates attended: (From)
/
Month
/
Day
Year
Dates attended: (To)
/
Month
/
Day
Year
Type of residency:
Did you successfully complete this program?
Yes
No
Please attach an explanation since you have selected no.
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Cancel
of
Were you the subject of any disciplinary action during your attendance at this institution?
Yes
No
Please attach an explanation since you have selected yes.
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Cancel
of
Did you have more than two residencies?
Yes
No
Please attach additional information that duplicates the information requested above:
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of
Do you have an fellowship to enter:
Yes
No
First Fellowship:
Institution Name:
Department Chair or Program Director:
First Name
Last Name
Department Chair or Program Director Degree:
Mailing Address:
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Dates attended: (From)
/
Month
/
Day
Year
Dates attended: (To)
/
Month
/
Day
Year
Type of fellowship:
Did you successfully complete this program?
Yes
No
Please attach an explanation since you have selected no.
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of
Were you the subject of any disciplinary action during your attendance at this institution?
Yes
No
Please attach an explanation since you have selected yes.
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Choose a file
Cancel
of
Do you have an second fellowship to enter:
Yes
No
Second Fellowship:
Institution Name:
Department Chair or Program Director:
First Name
Last Name
Department Chair or Program Director Degree:
Mailing Address:
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Dates attended: (From)
/
Month
/
Day
Year
Dates attended: (To)
/
Month
/
Day
Year
Type of fellowship:
Did you successfully complete this program?
Yes
No
Please attach an explanation since you have selected no.
Browse Files
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Cancel
of
Were you the subject of any disciplinary action during your attendance at this institution?
Yes
No
Please attach an explanation since you have selected yes.
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Cancel
of
Did you have more than two fellowships?
Yes
No
Please attach additional information that duplicates the information requested above:
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of
Do you have a teaching experience/faculty appointment to enter:
Yes
No
Teaching Experience/Faculty Appointment (Most Recent):
Institution Name:
Department Chair or Program Director:
First Name
Last Name
Department Chair or Program Director Degree:
Mailing Address:
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Dates attended: (From)
/
Month
/
Day
Year
Dates attended: (To)
/
Month
/
Day
Year
Rank/Position, if applicable:
Were you the subject of any disciplinary action during your attendance at this institution?
Yes
No
Please attach an explanation since you have selected yes.
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of
Do you have another teaching experience/faculty appointment to enter:
Yes
No
Teaching Experience/Faculty Appointment (Previous):
Institution Name:
Department Chair or Program Director:
First Name
Last Name
Department Chair or Program Director Degree:
Mailing Address:
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Dates attended: (From)
/
Month
/
Day
Year
Dates attended: (To)
/
Month
/
Day
Year
Rank/Position, if applicable:
Were you the subject of any disciplinary action during your attendance at this institution?
Yes
No
Please attach an explanation since you have selected yes.
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Cancel
of
Did you have more than two teaching experiences/faculty appointments?
Yes
No
Please attach additional information that duplicates the information requested above:
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of
Do you have and gaps in your training greater than 30 days?
Yes
No
Please upload document explaining why:
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Next
Section E: Hospital Membership - Current and Pending
Do you have any hospitals that you are a member of the Medical Staff and have clinical privileges or have applications for privileges pending?
Yes
No
Primary Hospital:
Hospital Name:
Address:
Street Address
Street Address Line 2
City
State
Zip Code
Membership Status:
Please Select
Active
Courtesy
Consulting
Adjunct
Suspended/Terminated/Resigned
Active Provisional Staff
Senior Staff
Associate
Provisional
Affiliate
Pending
Dates: (From)
/
Month
/
Day
Year
Date
Department/Division:
Department Phone Number:
Please enter a valid phone number.
Medical Staff Fax Number:
Please enter a valid phone number.
Any Limitations in Your Area of Specialty at this Hospital?
Do you have another hospitals that you need to enter where you are a member of the Medical Staff and have clinical privileges or have applications for privileges pending?
Yes
No
Other Hospital:
Hospital Name:
Address:
Street Address
Street Address Line 2
City
State
Zip Code
Membership Status:
Please Select
Active
Courtesy
Consulting
Adjunct
Suspended/Terminated/Resigned
Active Provisional Staff
Senior Staff
Associate
Provisional
Affiliate
Pending
Dates: (From)
/
Month
/
Day
Year
Date
Dates: (To)
/
Month
/
Day
Year
Date
Department/Division:
Department Phone Number:
Please enter a valid phone number.
Medical Staff Fax Number:
Please enter a valid phone number.
Any Limitations in Your Area of Specialty at this Hospital?
Do you have another hospitals that you need to enter where you are a member of the Medical Staff and have clinical privileges or have applications for privileges pending?
Yes
No
Other Hospital:
Hospital Name:
Address:
Street Address
Street Address Line 2
City
State
Zip Code
Membership Status:
Please Select
Active
Courtesy
Consulting
Adjunct
Suspended/Terminated/Resigned
Active Provisional Staff
Senior Staff
Associate
Provisional
Affiliate
Pending
Dates: (From)
/
Month
/
Day
Year
Date
Dates: (To)
/
Month
/
Day
Year
Date
Department/Division:
Department Phone Number:
Please enter a valid phone number.
Medical Staff Fax Number:
Please enter a valid phone number.
Any Limitations in Your Area of Specialty at this Hospital?
Back
Next
Section F: Hospital Membership - Previous
Do you have any hospitals that you previously held privileges other than during your Internship/Residency/Fellowship?
Yes
No
Hospital Name:
Address:
Street Address
Street Address Line 2
City
State
Zip Code
Membership Status:
Please Select
Active
Courtesy
Consulting
Adjunct
Suspended/Terminated/Resigned
Active Provisional Staff
Senior Staff
Associate
Provisional
Affiliate
Pending
Dates: (From)
/
Month
/
Day
Year
Date
Dates: (To)
/
Month
/
Day
Year
Date
Department/Division:
Department Phone Number:
Please enter a valid phone number.
Medical Staff Fax Number:
Please enter a valid phone number.
Any Limitations in Your Area of Specialty at this Hospital?
Do you have another hospitals that you need to enter where you are a member of the Medical Staff and have clinical privileges or have applications for privileges pending?
Yes
No
Hospital Name:
Address:
Street Address
Street Address Line 2
City
State
Zip Code
Membership Status:
Please Select
Active
Courtesy
Consulting
Adjunct
Suspended/Terminated/Resigned
Active Provisional Staff
Senior Staff
Associate
Provisional
Affiliate
Pending
Dates: (From)
/
Month
/
Day
Year
Date
Dates: (To)
/
Month
/
Day
Year
Date
Department/Division:
Department Phone Number:
Please enter a valid phone number.
Medical Staff Fax Number:
Please enter a valid phone number.
Any Limitations in Your Area of Specialty at this Hospital?
Do you have another hospitals that you need to enter where you are a member of the Medical Staff and have clinical privileges or have applications for privileges pending?
Yes
No
Hospital Name:
Address:
Street Address
Street Address Line 2
City
State
Zip Code
Membership Status:
Please Select
Active
Courtesy
Consulting
Adjunct
Suspended/Terminated/Resigned
Active Provisional Staff
Senior Staff
Associate
Provisional
Affiliate
Pending
Dates: (From)
/
Month
/
Day
Year
Date
Dates: (To)
/
Month
/
Day
Year
Date
Department/Division:
Department Phone Number:
Please enter a valid phone number.
Medical Staff Fax Number:
Please enter a valid phone number.
Any Limitations in Your Area of Specialty at this Hospital?
Back
Next
Do you have any ambulatory surgery centers where you currently have or previously held privileges other than during your Internship/Residency/Fellowship?
Option 1
Option 2
Option 3
ASC Name:
Address:
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Membership Status:
Please Select
Active
Courtesy
Consulting
Adjunct
Suspended/Terminated/Resigned
Active Provisional Staff
Senior Staff
Associate
Provisional
Affiliate
Pending
Dates: (From)
/
Month
/
Day
Year
Date
Dates: (To)
/
Month
/
Day
Year
Date
Do you have another any ambulatory surgery centers where you currently have or previously held privileges other than during your Internship/Residency/Fellowship to enter?
Yes
No
Section F: Hospital Membership - Previous
ASC Name:
Address:
Street Address
Street Address Line 2
City
State
Zip Code
Do you have any hospitals that you previously held privileges other than during your Internship/Residency/Fellowship?
Yes
No
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Membership Status:
Please Select
Active
Courtesy
Consulting
Adjunct
Suspended/Terminated/Resigned
Active Provisional Staff
Senior Staff
Associate
Provisional
Affiliate
Pending
Dates: (From)
/
Month
/
Day
Year
Date
Dates: (To)
/
Month
/
Day
Year
Date
Do you have another any ambulatory surgery centers where you currently have or previously held privileges other than during your Internship/Residency/Fellowship to enter?
Yes
No
ASC Name:
Address:
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Membership Status:
Please Select
Active
Courtesy
Consulting
Adjunct
Suspended/Terminated/Resigned
Active Provisional Staff
Senior Staff
Associate
Provisional
Affiliate
Pending
Dates: (From)
/
Month
/
Day
Year
Date
Dates: (To)
/
Month
/
Day
Year
Date
Back
Next
Section H: Work History
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Submit
Should be Empty: