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Home
About
Services
Adult Services
Pediatric Services
Veterans Services
Health and Wellness Coach
Non Skilled Care
Skilled Nursing Care
Long Term Care Insurance
Disability Care Services
Physical Therapy
Occupational Therapy
Speech Therapy
Blog
Service Areas
Careers
Employee Forms
Job Opportunities
Timesheet
Contact
Book an Appointment
Liability Insurance Agreement
If I do not have an active Professional Liability Insurance Policy and/or I have not provided a copy of my policy to Pleasant Care and Nurse Staffing, Corp.,
I,
Agree to have Pleasant Care and Nurse Staffing, Corp purchase a policy for me from the below options. I understand that the purchased Policy is mine and a copy will be provided to me. I may use my Policy at any and all other Registries, Agencies, and in my private professional life. The cost of this Policy will be deducted from my first compensation.
Agreed on this date:
(Required)
MM slash DD slash YYYY
Print Name:
(Required)
CM&F Liability Professional Information & Loss Information
Have you ever been indicted for, charged with, or convicted of, any act committed in violation of any law or ordinance other than traffic offenses?
(Required)
Yes
No
Have you ever had your hospital privileges, DEA license, healthcare license or reimbursement privileges, refused, denied, revoked, suspended, restricted, subject to a reprimand, placed on probation or voluntarily surrendered?
(Required)
Yes
No
Has any professional liability insurance company ever declined, refused, canceled or non-renewed your coverage?
(Required)
Yes
No
Have you ever been accused of sexual misconduct of any kind?
(Required)
Yes
No
Have you ever incurred or become aware of having a condition that impairs your ability to practice your medical specialty? (i.e. convulsive disorders, mental illness, multiple sclerosis, addiction to alcohol, narcotics or other controlled substances, etc).
(Required)
Yes
No
Are you now, or have you ever been, involved in a claim, or suit, arising out of the rendering or failure to render professional services, or related to any other coverage you are requesting from Medical Protective (e.g. CGL, EPLI, etc)?
(Required)
Yes
No
Are you aware of any complications, incident or adverse outcome resulting in injury or death that might reasonably result in a claim or suit against you? Amputation – Death – Loss of Vision – Permanent Neurological Injury
(Required)
Yes
No
In the last 12 months have your or anyone from your practice received a written request from an attorney for treatment records concerning any current or former patient(s) which might reasonably result in a claim or suit against you?
(Required)
Yes
No
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