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Gender M F

Coverage: Full-Time Part-Time

Group Practice: Yes No

Current Policy Form: Claims-Made Occurrence

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

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

Are you a member of any specialty-specific society or association?

Yes No

Do you use electronic medical records?

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