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P. Professional Liability Carrier:

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Prof_Liab_Carrier_id
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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:
  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?      
  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                                          
  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?      
  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                                          
  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?      
Records 1 to 6 of 6
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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:
 Has your professional liability insurance coverage ever been terminated, not renewed, cancelled, limited, restricted, modified, or altered by action of the insurance company?   
Professional Ins. A 1: Y/N



  
Professional Ins. Q 1 Date:
 / /   
Professional Ins. Q 2:
 Have you ever been denied coverage?  
Professional Ins. Q 2 Y/N:



  
Professional Ins. Q 2 Date:
 / /   
Professional Ins. Q 3:
 Has your present professional liability insurance carrier excluded any specific procedures from your insurance coverage?  
Professional Ins. A 3 Y/N:



  
Professional Ins. A 3 Date:
 / /   
Professional Ins. Q 4:
 Have there ever been any professional liability (i.e., malpractice) claims, suits, judgments, settlements or arbitration proceeding involving you?  
Professional Ins. A 4 Y/N:



  
Professional Ins. A 4 Date:
 / /   
Question 4. Details:
Professional Ins. Q 5:
 Are any professional liability (i.e., malpractice) claims, suits, judgments, settlements or arbitration proceeding involving you currently pending?   
Professional Ins. A 5 Y/N:



  
Professional Ins. A 5 Date
 / /   
Question A5 Details:
Professional Ins. Q 6:
 Are you aware of any formal demand for payment or similar claim submitted to your insurer that did not result in a lawsuit or other proceeding alleging professional liability?  
Professional Ins. A 6 Y/N:



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