Q. Disclosure questions:
| | | | |
|
| |
3 |
tim2 |
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? |
|
|
|
|