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Diagnostic Laboratory Professional Liability

Diagnostic Laboratory Professional Liability
* Required Information

Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Name of Facility
Contact Person's First name:*
    
Contact Person's Last name:*
Address 1
Address 2
City:
State:
Zip code:*
Phone numbers:
Daytime:*
Evening:
Fax:
E-Mail address:*

Type of Facility:





Specialty Type:













Hours of Operation M T W TH F
SAT SUN
Are the services provided in this facility limited to a
specific physician or medical group:

If yes, please indentify physician or medical group:

Current Insurance Company
Current Limits of Liability Each Claim
Aggregate
Desired Limits of Liability Each Claim
Aggregate
Last Annual Premium:
Requested Effective Date:

Current Coverage:

*Retroactive Date:
Have you ever been involved in a claim?

Number of Open Claims
Number of Closed Claims
Amount Paid or Settled?
If Yes, please give dates and status:

Please contact me at a future date:
I would prefer to be contacted:

How did you hear about us?

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We respect your right to privacy and all personal information will be protected.


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