APPLICATION FOR MISCELLANEOUS MEDICAL PROFESSIONAL LIABILITY INSURANCE (CLAIMS MADE)

I understand that signing this Application does not bind me to complete the insurance but agree that should an insurance policy be issued, this Application and the statements

THE UNDERWRITER’S ACCEPTANCE OF THIS APPLICATION OR THE MAKING OF ANY SUBSEQUENT INQUIRY DOES NOT BIND THE APPLICANT OR THE UNDERWRITER TO COMPLETE THE INSURANCE OR ISSUE A POLICY.

THE UNDERWRITER’S ACCEPTANCE OF THIS APPLICATION OR THE MAKING OF ANY SUBSEQUENT INQUIRY DOES NOT BIND THE APPLICANT OR THE UNDERWRITER TO COMPLETE THE INSURANCE OR ISSUE A

The completion of this application does not bind the Company to sell, nor the applicant to purchase this insurance, but any subsequent contract issued will be in full reliance upon

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially

The completion of this application does not bind the Company to sell nor the applicant to purchase this insurance, but any subsequent contract issued will be in full reliance upon

Signing this Application does not bind the applicant to accept the Insurance nor is the company bound to issue a policy. The applicant warrants that the answers to the above

If we or you cancel or non-renew this policy for any reason other than non-payment of premium, non-payment of de- ductible, non-compliance with any terms and conditions of this