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Are you presently in good physical and mental health?

Yes

Very Good Heath.

Have you ever been hospitalized, or treated for the abuse of alcohol or drugs?

No

 

Are you currently taking any medication that would impair or limit your ability to perform the duties and privileges requested?

No

 

Do you have any physical or mental limitations that would affect your performance, and/or you currently under the care of a Physician or Psychologist?

 

 

Are there any limitations on your health, life or disability insurance, or have you ever been denied or rated under any such coverage?

 

 

Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony?

 

 

Has your present or former professional liability carrier (s) excluded any specific procedures from your insurance coverage?

 

 

Has your present or former professional liability carrier ever denied or terminated your coverage?

 

 

Have any professional liability claims been filed against you?

 

 

Are there any claims presently pending?

 

 

Have any judgments been made against you in professional liability cases?

 

 

Have you entered into any settlements?

 

 

Has your medical license, certification or DEA registration in any jurisdiction ever been denied, limited, suspended or revoked?

 

 

Has your medical license, certification or DEA registration in any jurisdiction ever been voluntarily or involuntarily relinquished or subjected to probationary conditions?