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P. Professional Liability Carrier:

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Carrier Name:
Current/Former:
Carrier Policy Number:
Coverage Type:
Carrier Address:
Carrier City:
Carrier State:
Carrier Zip Code:
Name of Local Contact:
Carrier Phone Number:
Carrier Fax Number:
Effective Date:
Unlimited Coverage:
Tail Coverage:
Tail coverage details:
Carrier Original Effective Date:
Carrier Expiration Date:
Policy Limits Per Occurance:
Policy Limits in the Aggregate:
Retroactive Date:
Professional Ins. Q 1:
Professional Ins. A 1: Y/N
Professional Ins. Q 1 Date:
Professional Ins. Q 2:
Professional Ins. Q 2 Y/N:
Professional Ins. Q 2 Date:
Professional Ins. Q 3:
Professional Ins. A 3 Y/N:
Professional Ins. A 3 Date:
Professional Ins. Q 4:
Professional Ins. A 4 Y/N:
Professional Ins. A 4 Date:
Question 4. Details:
Professional Ins. Q 5:
Professional Ins. A 5 Y/N:
Professional Ins. A 5 Date
Question A5 Details:
Professional Ins. Q 6:
Professional Ins. A 6 Y/N:
Professional Ins. A 6 Date:
Question A6 Details:
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1
tim2
Hartford Insurance Co.
Current
6691981
 
23423 P.O. Box
Hartford
Cn.
12343
 
154.547.2541
 
 
 
 
 
08/15/2006
08/24/2012
100,000,000
500,000,000
08/19/2009
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  2 tim2 Medical Protective Insurance Group Former 16548138   999 First St. Longmont Co 81230   800.458.7941   06/12/2008 No No   05/06/1997 12/13/2012 1,000,000,000 10,000,000,000 01/02/2001                                          
  3 brb1 Test   Test Occurrence Test Test Test Test   Test           06/14/2005 06/13/2012 Test Test 06/19/2012 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?      
  4   Medical Protective Insurance Group   16548138   999 First St. Longmont Co 81230   800.458.7941   06/12/2008 No     05/06/1997 12/13/2012 1,000,000,000 10,000,000,000 01/02/2001 Has your professional liability insurance coverage ever been terminated, not renewed, cancelled, limited, restricted, modified, or altered by action of the insurance company?     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?      
  5                                           Has your professional liability insurance coverage ever been terminated, not renewed, cancelled, limited, restricted, modified, or altered by action of the insurance company?     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?      
  6                                           Has your professional liability insurance coverage ever been terminated, not renewed, cancelled, limited, restricted, modified, or altered by action of the insurance company?     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?      
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Carrier Name:
  
Current/Former:
   
Carrier Policy Number:
  
Coverage Type:
   
Carrier Address:
  
Carrier City:
   
Carrier State:
   
Carrier Zip Code:
   
Name of Local Contact:
   
Carrier Phone Number:
  
Carrier Fax Number:
   
Effective Date:
 / /   
Unlimited Coverage:
   
Tail Coverage:
   
Tail coverage details:
Carrier Original Effective Date:
 / /   
Carrier Expiration Date:
 / /   
Policy Limits Per Occurance:
   
Policy Limits in the Aggregate:
   
Retroactive Date:
 / /   
Professional Ins. Q 1:
   
Professional Ins. A 1: Y/N



  
Professional Ins. Q 1 Date:
 / /   
Professional Ins. Q 2:
   
Professional Ins. Q 2 Y/N:



  
Professional Ins. Q 2 Date:
 / /   
Professional Ins. Q 3:
   
Professional Ins. A 3 Y/N:



  
Professional Ins. A 3 Date:
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Professional Ins. Q 4:
   
Professional Ins. A 4 Y/N:



  
Professional Ins. A 4 Date:
 / /   
Question 4. Details:
Professional Ins. Q 5:
   
Professional Ins. A 5 Y/N:



  
Professional Ins. A 5 Date
 / /   
Question A5 Details:
Professional Ins. Q 6:
   
Professional Ins. A 6 Y/N:



  
Professional Ins. A 6 Date:
 / /   
Question A6 Details: