Ambulatory / Urgent Care Program Please fill out the form completely and click submit   Corporate Name Street Address City   State Zip Contact Name   Email Phone   Fax Professional Liability Information City State Non-Diagnostic Visits (Physical, shots, etc.) Diagnostic Visits Retroactive Date   Claim Information Date of Claim Amount Paid / Reserved State Status Open Closed Open Closed Open Closed Open Closed Open Closed   Limits Non-Physician Employee Type Deductible / SIR $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,500,000 $1,000,000 / $3,000,000   Current Insurance Provider Exp. date of Coverage  Current Premium Comments Do Physicians have hospital admitting privileges?              Yes No Do Physicians / hospital follow-ups on their patients?        Yes No