Surgi Center Program
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Corporate Name
Street Address
City
  State Zip
Contact Name
  Email
Phone
  Fax
Professional Liability Information
City State General Anesthesia
Surgies / Year 		Local Anesthesia
Surgies / Year 		Retroactive
Date 		# Overnight
Beds
 
Claim Information
Date of Claim Amount Paid / Reserved State Status
 
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