GENERAL INFORMATION |
Name |
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Contact Name |
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Phone |
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Fax |
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Email |
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Street |
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City,
State,
Zip |
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State of Incorporation |
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Date of Incorporation
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Type of Organization |
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Type of Business Entity |
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Tax Status |
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Continually operating since |
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Description of business |
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COMPANY INFORMATION |
Total number of employees |
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Does the applicant own or operate any type of medical facility? If yes, please explain |
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Does the applicant employ health care professionals in any capacity, other than administrative duties, such as medical director, peer review or utilization review? If yes, please list. |
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Total Current assets of applicant organization: |
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Total est. revenues for current calendar year: |
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INSURANCE COVERAGE INFORMATION |
Current Insurance
(if none, most recent) |
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Has any insurer declined, canceled or non-renewed any Directors and Officers insurance coverage? |
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PRIOR CLIAMS INFORMATION |
Have there been or are there now pending any liability claims against the applicant? If so, please explain. |
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LIABILITY EXPOSURES |
Please describe your operations, including any services you provide to others for a fee. |
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FEE BASED SERVICES |
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STATE BREAKDOWN (IF YOU CONTRACT WITH PROVIDERS THIS SECTION IS MANDATORY): |
Please provide enrollment and required physician medical malpractice limits by state. |
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Number of employees selling insurance products |
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Number of those employees licensed |
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Please describe all duties of sales employees |
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Nature and type of products/services sold. Please indicate percentage of total revenue for each product. |
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Thank you very much for taking the time to contact us.
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