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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:	Freestanding- Hospital Satellite Freestanding - Independent Hospital - Based	Physician's Office Mobil Unit (specify area of operations) Other
Specialty Type:	Chemistry Clinical Cytogenetics Hematopogy Histocompatibility Immunohematology Microbiology Pathology - Cytology	Pathology - Histopathology Pathology - Ocular Pathology - Oral Pathology - Other Radiobioassay Other (specify)
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:	Yes No
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:	Claims Made* Occurrence
*Retroactive Date:
Have you ever been involved in a claim?	Yes No
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:	via email via telephone via fax in the mail
How did you hear about us?

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