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CONTACT INFORMATION
* Name
* Phone
* Address
Fax
* Email
* City
* State
* Zip
PRACTICE INFORMATION
* Primary Area of Practice
No Surgery Minor Surgery Major Surgery
Secondary Area of Practice
No Surgery Minor Surgery Major Surgery
* Full Time or Part Time
Full Time Part Time Practice
If part time number of hours
If part time the year you started part time
TYPE OF PRACTICE
* Sole Practitioner
Yes No
* Group
Yes No
If you answered yes on Group Practice how many are in your group?
* Part of a Corporation
Yes No
If you are a part of a Corporation what is the legal name of that Corporation
PERCENT OF PRACTICE
* Home Visits Percent
* Assisted Living Visits Percent
* Nursing Home Visits Percent
* Office Visits Percent
Other (describe) Percent
CURRENT POLICY INFORMATION
* Current insurer
* Policy expiration date
Retroactive date (if claims made)
Number of years without a paid claim or notice of intent
1-5 6-10 11-20
Limit of Liability:
$100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1.5MM $1MM/$3MM
Verification	Fill in the text