| Current policy effective date |
|
expiration date |
|
| Prior acts/Retroactive date |
|
| Number of employees with patient contact |
|
| Type of practice or specialty |
|
| 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 |
|
