| Physician Names |
Retro Date |
Type of practice or specialty |
If cardiovascular - Invasive or Non-Invasive |
Board Cert. |
Surgery/ Non-surgery |
| Current policy effective date |
|
expiration date |
|
| Years operating as a practice |
|
| Number of employees with patient contact |
|
| Current limits of Liability |
|
| Separate/Shared Limits for Entity |
|
| How many locations outside Kentucky? |
|
| What Percentage of Practice (revenue-wise) do these
locations represent? |
|
| Are You within 5 years of Retirement? |
Yes
No
Don't know
|
| Claim History (please provide
complete details) |
|
| Estimated amount of paid claims |
|
| How many closed without pay |
|
