CPH Mental & Behavioral Health

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Malpractice Insurance Application for Individual Allied Health, Mental Health, and Nurse Providers

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Welcome back ,

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

No previous coverage selections from last year’s policy will 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
Individual Allied Health, Mental Health, and Nurse Providers

This Application is for New Individual Applicants Only | Existing Policyholders: Click Here to Renew

Welcome back ,

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

No previous coverage selections from last year’s policy will 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.

Yes, I understand.

Do you own an LLC or Corporation (or a PC, PA, LP, PLLC, or Nonprofit)?

Yes

Corporate coverage is appropriate for 1 person/single owner companies AND companies with employees. Applying for corporate coverage will protect both you individually and your business entity.
LEARN MORE

Would you like corporate coverage to insure yourself and your business entity?

Yes, I'd like to protect my company

No, I want to decline coverage for my company

Continue to Corporate Application

Professional Liability - Previous Selections
Edit	State of Residence
Edit	Occupation
Edit	Employment Category	Employed Self-Employed Both Employed and Self-Employed
Edit	Part-time or Full-time
Edit	Number of hours you work
Edit	Limits of Liability	$ per occurrence / $ aggregate
Edit	Professional Association	None
	Additional Occupations

State of Residence:

Select your Desired Effective Date:

Select your Area of Practice or Study:

Select your Occupation:

Start typing your occupation or scroll

Art Therapist

Associate Counselor

Associate Marriage and Family Therapist (AMFT)

Audiologist

BCBA Tutor

Behavior Consultant

Behavior Specialist

Behavior Technician

Behavior Therapist

Bio-Med Tech

Blood Bank Tech

Board Certified Assistant Behavior Analyst

Board Certified Behavior Analyst

Board Certified Behavior Analyst - Doctoral

Cardiology Tech

Case Manager

Certified Case Manager

Certified Medical Assistant

Certified Nutritional Consultant

Certified Nutritional Counselor

Certified Peer Recovery

Certified Rehabilitation Professional

Clinical Lab Tech

Clinical Social Worker

Community Health Tech

Counselor

Counselor Intern (CI)

Developmental Therapist

Dialysis Tech

Dietitian

Doctoral Student

Drama Therapist

Drug and Alcohol Counselor

EAP

Early Childhood Interventionist

EIA Supervisor

Health Registrar Tech

Histologic Tech

Lab Tech

Licensed Alcohol and Drug Counselor

Licensed Assistant Behavior Analyst

Licensed Associate Counselor

Licensed Behavior Analyst

Licensed Clinical Mental Health Counselor

Licensed Clinical Professional Counselor

Licensed Clinical Psychologist

Licensed Clinical Social Worker

Licensed Educational Psychologist

Licensed Marriage and Family Therapist

Licensed Master of Social Work (LMSW)

Licensed Mental Health Counselor

Licensed Professional Clinical Counselor

Licensed Professional Counselor

Licensed Professional Counselor Associate

Licensed Professional Counselor/Mental Health Service Provider

Licensed Psychologist

Licensed Social Worker (LSW)

Limited Licensed Professional Counselor

Limited Licensed Psychologist

LPN

LVN

Marriage & Family Therapist Intern (MFT-I)

Marriage and Family Therapist (Licensed)

Masters Level Psychologist

Med. Tech Assistant

Mental Health Technician

Music Therapist

Nationally Certified Counselor

Nuclear Med Tech

Nurse Aide/Assistant

Nutritionist

Occupational Therapist

Optician

Post Masters/ Intern under supervision

Post Masters/MFT Intern Under Supervision

Post-Doctoral Under Supervision

Pre-Clinical Fellow

Professional Clinical Counselor Intern (PCC Intern)

Provisional Licensed Clinical Professional Counselor

Provisional Licensed Professional Counselor

Psychoanalyst (Master's Level)

Psychological Assistant

Psychological Associate

Psychological Examiner

Psychologist (Licensed)

Qualified Mental Health Professional

Radiation Therapist

Radiological Tech

Recreational Therapist

RN (non-OBGYN/Neo-natal)

School Counselor

School Psychologist

Social Worker

Speech Language Pathologist

Speech Pathologist

Student - Allied Health

Student - Behavior Analysis

Student - Mental Health

Student - Nurse

Student - Social Worker

Unlicensed Psychotherapist

X-Ray Tech

Do you provide respite care, homemaker or companion services?

Yes

Applicants providing direct support (companion care, respite, living skills, homemaker, etc) are eligible for coverage in an alternate CPH program. Continue below to the appropriate application and choose “Direct Support Professional” as your designation. Applicants providing direct support (companion care, respite, living skills, homemaker, etc) are eligible for coverage in an alternate CPH program. Continue below to the appropriate application and choose “Home Health Aide” as your designation.

Continue to Application

Are you providing home studies and/or foster care/adoption placement services?

Yes

Please provide a detailed description of your foster case/adoption services:

What percentage of your overall services do home studies and/or foster care/adoption placement services make up?

Do you provide respite care, homemaker or companion services?

Yes

Please provide a detailed description of your respite care/companion services:

Select your Professional Association:

We require all Licensed Marriage and Family Therapists (and interns) to maintain current membership in either the American Association for Marriage and Family Therapy (AAMFT) or the California Association of Marriage and Family Therapists (CAMFT).

Is your membership active?

Yes

Class

Class A - Adult / Geriatric / Family Planning / Women’s Health / Adult Oncology
Class B - Psychiatric
Class C - Pediatric / Neonatal / Family Practice / Acute Critical Care

What is your expected graduation date?

Please use your best guess*

What date do you expect to earn your full licensure?

Please use your best guess*

What date do you expect to earn your full licensure?

Please use your best guess*

Select your employment category:

W2 Employed

1099 / Self-Employed

Both W2 Employed and 1099 / Self-Employed

Please Indicate the number of hours you work per week on a self-employed basis.

0-10 hours a week

11-20 hours a week

over 20 hours a week

Employment Category (24 hour or more is Full-Time):

Part-time

Full-time

Select your limits of liability:

$1,000,000 each occurrence / $3,000,000 aggregate

$1,000,000 each occurrence / $5,000,000 aggregate

$2,000,000 each occurrence / $4,000,000 aggregate

$5,000,000 each occurrence / $5,000,000 aggregate

*All categories cover any number of hours as a W2 employee

Have you recently become licensed for the very first time?

Select Yes if you have been licensed or certified for the first time in the last 2 years3 years.

Yes

Select the Month and Year that you were first licensed or certified.

Based on the date provided, you do not qualify for the newly licensed discount

Have you recently become licensed for the very first time?

If you have been licensed or certified for the first time in the last 2 years3 years.

Based on your date of licensure (), you qualify for an additional newly licensed discount. This will be automatically applied to your premium.

Have you completed Law and/or Ethics CEUs in the last 24 months?

You must have completed at least the minimum number of Continuing Education Units (CEU’s) in law and/or ethics that are required by your state for licensing renewal or by your national certification body for certification renewal.

Yes

Professional Liability Premium	$0.00 for $ per occurrence / $ aggregate limits
Newly Licensed Discount	$0.00
Risk Management Discount	$0.00
5% Online Discount	$0.00
Professional Liability Subtotal	$0.00
CPH TOP Premium	$0.00
General Liability Premium	$0.00
Additional Insured Premium	$0.00
State Lincensing Board Increase Premium	$0.00
Sexual Abuse and Molestation Premium	$0.00
State Taxes 2022-1 FIGA Assessment Surcharge	$0.00
Municipal Taxes	$0.00
Administrative Fee	$20.00
Total Annual Premium	$20.00

Taxes for FL, KY, LA, NJ, and WV are not included

Please select an address from the list below:

Street	City	Zipcode	State

Please enter a valid suite, or unit and number and click "update".

Please enter a valid address.

Address 1

Address 2

City

State

Zipcode

Please select the best match below:

Street	Street 2	City	Zipcode	State

Street	Street 2	City	Zipcode	State

Do not update, use address as entered:
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Choose the Account from PATH to use for this Quote:
Filtered result / results in total

	PHLY Risk Clearance	Street	City	State	Zipcode	Fein	AccountNumber	Phone

Malpractice Insurance Application for Individual Allied Health, Mental Health, and Nurse Providers

Malpractice Insurance Application for
Individual Allied Health, Mental Health, and Nurse Providers

Premium Summary

Policy Successfully Processed

Payment Completed Successfully. A copy of your policy documents will be e-mailed to

For your free first-time listing in Psychology Today's Therapy Directory - $180 value from CPH!

Thank you for choosing us.

Malpractice Insurance Application for Individual Allied Health, Mental Health, and Nurse Providers

Malpractice Insurance Application forIndividual Allied Health, Mental Health, and Nurse Providers

Premium Summary

Policy Successfully Processed

Payment Completed Successfully. A copy of your policy documents will be e-mailed to

For your free first-time listing in Psychology Today's Therapy Directory - $180 value from CPH!

Thank you for choosing us.

Malpractice Insurance Application for
Individual Allied Health, Mental Health, and Nurse Providers