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Name of Applicant:
Gender:	M   F
Contact Name:
Current Insurer:
Address:
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Current Specialty:
Please circle if you wish:	Full-Time Coverage Part-Time Coverage
Group practice:	Yes No
Requested Effective Date:
Current Policy Form:	Claims-Made Occurrence
What year did you complete medical school?
Are you Board Certified?	Yes No
Has any hospital ever taken action to suspend, revoke or restrict your medical staff privileges?	Yes No
Did you complete a fellowship?	Yes No
Have you ever suffered from or been treated for any substance abuse, disability, mental illness or serious physical injury or illness that has or might affect your ability to practice medicine?	Yes No
Do you currently practice or plan to practice medicine or surgery outside the state of New Jersey?	Yes No
Have you had any medical malpractice claims, settlements or judgements against you during the previous ten years?	Yes No
If your previous policy was claims-made, did you, or are you planning to obtain an extended reporting period (tail) endorsement?	Yes No
Have you ever practiced without professional liability insurance?	Yes No