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CPH Liability Insurance

CPH Healthcare Liability Insurance

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General Information Complete Purchase Complete Finance Agreement

IMPORTANT

CPH has loaded some information from the previous policy with Covery's (Pro select Insurance).
Please complete any fields that are incomplete and update any fields that have changed.

Prior Policy Information
Name Insured: Policy Number:
Policy Period: -
Policy Type: Occurrence
New Policy Effective Date:

IsCorporate

Please be advised this policy will provide individual coverage only and will not insure your company.

DoNotDisplayT

Firm/Corporate coverage is currently unavailable and will be available in the coming weeks. Please check back soon!

CorporateMultipleEmployees IsCompanyT
ShowStateQT
UnallowedStateT

Coverage is currently not available in . Please check back at a later date.

OccupationCategory NotMultipleEmployeesT QStateAnsweredT AllowedStateT
NotMultipleEmployeesT QStateAnsweredT OccupationCategoryFilledT AllowedStateT

Please select your Occupation

IsCoverysCarrierT OccPhysicianAssistantT NotMultipleEmployeesT

Are you involved in any following activities (check all that apply):

Please select an option

OccPhysicianAssistantT
OccNursePractitionerT IsCoverysCarrierT DoNotDisplayT
OccNursePractitionerT IsCoverysCarrierT

Select your Specialty (check all that apply):

Please select your specialty

ShowAddOccupationsT
NotStudentT NotMultipleEmployeesT

You can select multiple occupations below.

# Occupation to be Covered Charge Status

No Additional Occupations defined

Add Additional Occupation

ShowPolicyTypeT NotMultipleEmployeesT
ShowPolicyTypeT NotMultipleEmployeesT

Policy Type: Occurrence
Retroactive Date:

Modified Claims made policies are being converted to occurrence. Coverys is providing free tail coverage for the expiring policy.

IsCoverysCarrierT NotMultipleEmployeesT

Do you work in any of these environments?

Please select an option

PrisonPercentageQuesT NotMultipleEmployeesT
SeniorFacilityPercentageQuesT IsCompanyT DoNotDisplayT
NotMultipleEmployeesT IsCompanyT
EmploymentStatus ShowEmpStatusQT
HoursPerWeek ShowHoursPerWeekT IsMedproCarrierT
HoursPerWeek ShowHoursPerWeekT IsCoverysCarrierT IsIndividualT
HoursPerWeek IsCoverysCarrierT IsCompanyT NotMultipleEmployeesT ShowHoursPerWeekT

Must be between 1 and 40

HoursPerWeek IsPhlyCarrierT NotEmployeeStatusT
QLicenseLast12MonthT IsMedproCarrierT
AssociationMember ShowAssociationQuesT

Please select “Yes” to review the list of professional associations, certifying bodies, and affiliates:

Association QIsAssociationMember IsMedproCarrierT
OtherAssociation QOtherAssociation
LimitsOfLiability ShowMainLimitsQT
ShowMainLimitsQT

/

ShowMainLimitsQT
ShowRecentlyLicenseLabelT

Have you recently become licensed for the very first time?
Yes, on

RecentlyLicensed ShowRecenLicQT
IsNotRenewalT
ShowPLRiskQT IsIndividualT
ShowPLRiskQT IsCompanyT NotMultipleEmployeesT
ShowCountyT IsCoverysCarrierT NotMultipleEmployeesT ShowEffDateQuesT

EffDate ShowEffDateQuesT
NotMultipleEmployeesT

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.

IsIndividualT

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

RecentlyLicensedDiscountNotEligibleT

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

Premium Summary

Below is a quote based on the information provided. You can add additional coverages in the following steps.
Total Annual Premium $0.00
Limits of liability $ per occurrence and $ aggregate.
Taxes for FL, KY and SC are not included

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Policy Number:

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