CPH Mental & Behavioral Health

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CPH Liability Insurance

Allied Health Business Entity

English

Malpractice Application

Welcome back ,

We understand that your insurance needs may stay the same from year-to-year and sometimes they change:

All previous coverage selections from last year’s policy may NOT carry over to this application. Please re-enter on this application any additional insureds, general liability, property coverage or any other selections desired. (Please reference last year’s application/policy documents in your customer portal if you are unsure what you chose.)
*Click the box below to acknowledge you understand.

We have loaded most of the selections from the previous policy. We do require you to complete some questions to verify that nothing has changed. Please go through the application and confirm everything on your application before completing the renewal.

I understand the above statement

Malpractice Insurance Application for Outpatient Counseling
Group Entity/Corporate or Non-Profit Coverage

Company Name:

Owner First Name:

Owner Middle Initial:

Owner Last Name:

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Phone:

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Current Carrier:

Please put "NONE" if you do not currently have a Professional Liability policy

⮞ Have the professional services you provide changed since your last application?

Yes

⮞ Please provide a description of services provided at your company:

Company Website address

Please provide the website address for the business you own. If you do not have an active business website, please leave this field blank or put “NONE.

Please provide a detailed description of services provided at your company

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Allied Health Business Entity

Malpractice Insurance Application for Outpatient CounselingGroup Entity/Corporate or Non-Profit Coverage

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Malpractice Insurance Application for Outpatient Counseling
Group Entity/Corporate or Non-Profit Coverage