Home / Applications / Physicians and Surgeons / Utah Checklist
Please use the checklist below to ensure that you submit all required application forms.
__ Application for Reporting Policy - Medical Professional Liability Insurance
__ Application for Prior Acts Coverage, if applying for Prior Acts
__ Underwriting Requirements for Physician Applicants
__ Prior Insurance Information Chart
__ Payment Plan Selection
__ Supplement to Application for Medical Malpractice Insurance, if you practice one of the following specialties:
Cardiology
Cosmetic Surgery
Dermatology
Family Practice/General Practice
General Surgery
Gynecology
Hand Surgery
Hospitalist
Obstetrics
Ophthalmology
Orthopedics
Otolaryngology
Pathology
Peripheral Vascular Surgery
Physical Medicine & Rehabilitation
Plastic Surgery
Radiology/Nuclear Medicine
Thoracic Surgery (Cardiovascular)
Urology
__ Limited Medical Practice Application, if applying for part-time coverage
Limited Practice Application - Hospital Department or Facility Based
Limited Practice Application - Office Based
__ Experience Verification Letter - please complete and send this letter to both your present and your previous medical malpractice insurance carriers from the past ten years. Experience verification instructions.
__ Additional Insured Applications, if you employ any of the following extended role providers, and would like to apply for coverage under your policy.
Additional Insured - Acupuncturist
Additional Insured - Certified Registered Nurse Anesthetist
Additional Insured - Dentist
Additional Insured - First Assist
Additional Insured - Nurse Practitioner
Additional Insured - Certified Nurse Midwife
Additional Insured - Occupational/Physical Therapist
Additional Insured - Optometrist
Additional Insured - Perfusionist
Additional Insured - Physician
Additional Insured - Physician's Assistant
Additional Insured - Psychologist
|
