Information Section or ACORD 825 Professional / Specialty Insurance Application (For
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 196 (2013/09)
Medical Professional Liability
Insurance Application
ACORD 196, Medical Professional Liability Insurance Application, is
used to apply for medical professional liability insurance coverage. ACORD 196 is a self-
contained application. It is not necessary to use another ACORD form with this
application, including ACORD 125, Commercial Insurance Application - Applicant
Information Section or ACORD 825 Professional / Specialty Insurance Application (For
Use in Management, Executive & Professional Lines - Applicant Section).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Agency Address
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION
Enter identifier: The agency's state license number. As used here, this is required in
Nebraska.
IDENTIFICATION SECTION
Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION
Phone
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION
Fax
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION
Email Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION
Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION
Sub Code
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
person) within a producer's office (e.g. agency or brokerage).
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Applicant (First Name Insured)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Social Security #
Enter identifier: The tax identifier of the named insured.
IDENTIFICATION SECTION
DEA # (If Applicable)
Enter identifier: The identifier for the named insured assigned by the USA Drug
Enforcement Agency.
IDENTIFICATION SECTION
US Citizen? Yes (Checkbox)
Check the box (if applicable): Indicates the named insured is a citizen of the United States
of America.
IDENTIFICATION SECTION
US Citizen? No (Checkbox)
Check the box (if applicable): Indicates the named insured is not a citizen of the USA.
IDENTIFICATION SECTION
Date Of Birth
Enter date: The date of birth of the insured.
IDENTIFICATION SECTION
Primary Business Address
Enter text: The first address line of the physical location.
IDENTIFICATION SECTION
Enter text: The second address line of the physical location.
IDENTIFICATION SECTION
Enter text: The city of the physical location.
IDENTIFICATION SECTION
Enter code: The state or province of the physical location.
IDENTIFICATION SECTION
Enter code: The postal code of the physical location.
IDENTIFICATION SECTION
Phone
Enter number: The named insured's primary phone number.
IDENTIFICATION SECTION
Mailing Address
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line two.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address postal code.
COVERAGES / LIMITS
Claims Made (Checkbox)
Check the box (if applicable): Indicates the coverage trigger is on a claims-made basis
on a medical professional liability policy.
COVERAGES / LIMITS
Occurrence (Checkbox)
Check the box (if applicable): Indicates the coverage trigger is on an occurrence basis on
a medical professional liability policy.
COVERAGES / LIMITS
Aggregate ($)
Enter limit: The liability aggregate limit amount.
COVERAGES / LIMITS
Each Occurrence ($)
Enter limit: The liability each occurrence limit amount.
COVERAGES / LIMITS
Other ($)
Enter limit: The coverage limit amount.
COVERAGES / LIMITS
Other Description
Enter text: The description of the coverage.
COVERAGES / LIMITS
Proposed Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence. As used here, this is the proposed effective date.
COVERAGES / LIMITS
Proposed Retroactive Date
Enter date: The retroactive date you are requesting for the policy being applied for. This is
the proposed earliest date for which an occurrence could trigger coverage under a
Claims Made policy.
PROFESSION
Physician (Checkbox)
Check the box (if applicable): Indicates the named insured is a physician.
PROFESSION
Primary Practice
Enter text: The description of the primary practice of the physician.
PROFESSION
Secondary Practice
Enter text: The description of the secondary practice of the physician.
PROFESSION
Surgeon (Checkbox)
Check the box (if applicable): Indicates the named insured is a surgeon.
PROFESSION
Specialty
Enter text: The description of the surgeon's specialty.
PROFESSION
Other
Enter text: The description of the surgeon's other practice / specialty.
PROFESSION
Physician's Assistant (Checkbox)
Check the box (if applicable): Indicates the named insured is a physician's assistant.
PROFESSION
Nurse Anesthetist (Checkbox)
Check the box (if applicable): Indicates the named insured is a nurse anesthetist.
PROFESSION
Surgeon's Assistant (Checkbox)
Check the box (if applicable): Indicates the named insured is a surgeon assistant.
PROFESSION
Psychologist (Checkbox)
Check the box (if applicable): Indicates the named insured is a psychologist.
PROFESSION
Nurse Midwife (Checkbox)
Check the box (if applicable): Indicates the named insured is a nurse midwife.
PROFESSION
Perfusionist (Checkbox)
Check the box (if applicable): Indicates the named insured is a perfusionist.
PROFESSION
Registered Nurse (Checkbox)
Check the box (if applicable): Indicates the named insured is a registered nurse.
PROFESSION
Licensed Practical Nurse
(Checkbox)
Check the box (if applicable): Indicates the named insured is a licensed practical nurse.
PROFESSION
Optometrist (Checkbox)
Check the box (if applicable): Indicates the named insured is an optometrist.
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Section Name
Field Name
Field and/or Section Description
PROFESSION
Emergency Medical Technician
(Checkbox)
Check the box (if applicable): Indicates the named insured is an emergency medical
technician.
PROFESSION
Nurse Practitioner (Checkbox)
Check the box (if applicable): Indicates the named insured is a nurse practitioner.
PROFESSION
Counselor (Checkbox)
Check the box (if applicable): Indicates the named insured is a counselor.
PROFESSION
Other (Checkbox)
Check the box (if applicable): Indicates the named insured's occupation is other than those
listed.
PROFESSION
Other (Specify) Field
Enter text: The named insured's primary occupation or business activity.
PERSONAL INFORMATION Held
Type Of Certification Currently
Enter text: The description of certifications held by the named insured.
PERSONAL INFORMATION State One
Enter code: The state or province issuing the license.
PERSONAL INFORMATION License # One
Enter identifier: The license number.
PERSONAL INFORMATION State Two
Enter code: The state or province issuing the license.
PERSONAL INFORMATION License # Two
Enter identifier: The license number.
PERSONAL INFORMATION State Three
Enter code: The state or province issuing the license.
PERSONAL INFORMATION License # Three
Enter identifier: The license number.
EDUCATION
Institution One
Enter text: The name of the school or educational institution.
EDUCATION
Dates Of Attendance-Mo/Yr One-A
Enter date: The date (MM/YYYY) the named insured started attending the school or
education institution.
EDUCATION
Dates Of Attendance-Mo/Yr One-B
Enter date: The date (MM/YYYY) the named insured stopped attending the school or
education institution.
EDUCATION
Date Graduated One
Enter date: The date (MM/YYYY) the named insured graduated from the school or
education institution.
EDUCATION
Certification Or Degree Received
One
Enter text: The certification or degree received.
EDUCATION
Institution Two
Enter text: The name of the school or educational institution.
EDUCATION
Dates Of Attendance-Mo/Yr Two-A
Enter date: The date (MM/YYYY) the named insured started attending the school or
education institution.
EDUCATION
Dates Of Attendance-Mo/Yr Two-B
Enter date: The date (MM/YYYY) the named insured stopped attending the school or
education institution.
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Section Name
Field Name
Field and/or Section Description
EDUCATION
Date Graduated Two
Enter date: The date (MM/YYYY) the named insured graduated from the school or
education institution.
EDUCATION
Certification Or Degree Received
Two
Enter text: The certification or degree received.
EDUCATION
Institution Three
Enter text: The name of the school or educational institution.
EDUCATION
Dates Of Attendance-Mo/Yr Three-
A
Enter date: The date (MM/YYYY) the named insured started attending the school or
education institution.
EDUCATION
Dates Of Attendance-Mo/Yr Three-
B
Enter date: The date (MM/YYYY) the named insured stopped attending the school or
education institution.
EDUCATION
Date Graduated Three
Enter date: The date (MM/YYYY) the named insured graduated from the school or
education institution.
EDUCATION
Certification Or Degree Received
Three
Enter text: The certification or degree received.
EDUCATION
List Continuing Education Courses
And Credits Received Within Last
2 Years (Or Attach Copies Of
Certificates And/Or Credits
Received)
Enter text: The description of continuing education courses and credits received within the
stated number of years.
EDUCATION
Has Your Certification/License In
Any State Ever Been (Voluntarily
Or Otherwise) Suspended, Denied,
Revoked, Restricted Or Limited In
Any Way? If Yes, Explain-YES
(Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, Has your
certification / license in any state ever been (voluntarily or otherwise) suspended, denied,
revoked, restricted or limited in any way?.
EDUCATION
Has Your Certification/License In
Any State Ever Been (Voluntarily
Or Otherwise) Suspended, Denied,
Revoked, Restricted Or Limited In
Any Way? If Yes, Explain-NO
(Checkbox)
Check the box (if applicable): Indicates a No response to the question, Has your
certification / license in any state ever been (voluntarily or otherwise) suspended, denied,
revoked, restricted or limited in any way?.
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Section Name
Field Name
Field and/or Section Description
EDUCATION
Has Your Certification/License In
Any State Ever Been (Voluntarily
Or Otherwise) Suspended, Denied,
Revoked, Restricted Or Limited In
Any Way? If Yes, Explain-Other
Field
Enter text: An explanation as to whether the applicant's certification / license in any state
has ever been (voluntarily or otherwise) suspended, denied, revoked, restricted or limited
in any way.
EDUCATION
Current Practice (Describe General
Duties And Extent Of Supervision
(If Any)
Enter text: The description of the current practice including general duties and extent of
supervision (if any).
EDUCATION
List Any
Association/Society/Memberships
Related To Your Profession
Enter text: The name of the affiliated organization(s) to which the individual has an
affiliation. If no affiliation exists, indicates none or not applicable.
EDUCATION
Enter text: The name of the affiliated organization(s) to which the individual has an
affiliation. If no affiliation exists, indicates none or not applicable.
EDUCATION
Enter text: The name of the affiliated organization(s) to which the individual has an
affiliation. If no affiliation exists, indicates none or not applicable.
EDUCATION
Enter text: The name of the affiliated organization(s) to which the individual has an
affiliation. If no affiliation exists, indicates none or not applicable.
EDUCATION
Enter text: The name of the affiliated organization(s) to which the individual has an
affiliation. If no affiliation exists, indicates none or not applicable.
EDUCATION
Present Employees And Positions
Enter text: The full name of the employee.
EDUCATION
Enter text: The title this person has in the current employment position.
EDUCATION
Enter text: The full name of the employee.
EDUCATION
Enter text: The title this person has in the current employment position.
EDUCATION
Enter text: The full name of the employee.
EDUCATION
Enter text: The title this person has in the current employment position.
EDUCATION
Enter text: The full name of the employee.
EDUCATION
Enter text: The title this person has in the current employment position.
EDUCATION
Enter text: The full name of the employee.
EDUCATION
Enter text: The title this person has in the current employment position.
LOSS HISTORY
Chk Here If None (Checkbox)
Check the box (if applicable): Indicates there are no prior losses or occurrences that may
give rise to claims for the mandated number of years.
LOSS HISTORY
See Attached Loss Summary
(Checkbox)
Check the box (if applicable): Indicates that a loss summary report is attached to the
application.
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Section Name
Field Name
Field and/or Section Description
LOSS HISTORY
Date Of Occurrence One
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type / Description Of Occurrence
Or Claim One
Enter text: A brief description of the loss.
LOSS HISTORY
Date Of Claim One
Enter date: The date the claim was filed.
LOSS HISTORY
Amount Paid One
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Amount Reserved One
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY
Claim Status-Open (Checkbox)
One
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY
Claim Status-Closed (Checkbox)
One
Check the box (if applicable): Indicates the claim is closed.
LOSS HISTORY
Date Of Occurrence Two
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type / Description Of Occurrence
Or Claim Two
Enter text: A brief description of the loss.
LOSS HISTORY
Date Of Claim Two
Enter date: The date the claim was filed.
LOSS HISTORY
Amount Paid Two
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Amount Reserved Two
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY
Claim Status-Open (Checkbox)
Two
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY
Claim Status-Closed (Checkbox)
Two
Check the box (if applicable): Indicates the claim is closed.
LOSS HISTORY
Date Of Occurrence Three
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type / Description Of Occurrence
Or Claim Three
Enter text: A brief description of the loss.
LOSS HISTORY
Date Of Claim Three
Enter date: The date the claim was filed.
LOSS HISTORY
Amount Paid Three
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Amount Reserved Three
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY
Claim Status-Open (Checkbox)
Three
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY
Claim Status-Closed (Checkbox)
Three
Check the box (if applicable): Indicates the claim is closed.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
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Section Name
Field Name
Field and/or Section Description
PRIOR CARRIER
INFORMATION
Carrier One
Enter text: The name of the previous insurer.
PRIOR CARRIER
INFORMATION
Policy Number One
Enter identifier: The policy number of the previous coverage.
PRIOR CARRIER
INFORMATION
Policy Type-Claims Made
(Checkbox) One
Check the box (if applicable): Indicates the coverage trigger is on a claims-made basis
on a medical professional liability policy.
PRIOR CARRIER
INFORMATION
Policy Type-Occurrence
(Checkbox) One
Check the box (if applicable): Indicates the coverage trigger is on an occurrence basis on
a medical professional liability policy.
PRIOR CARRIER
INFORMATION
Retro Date One
Enter date: The retroactive date for the policy being described. This is the date for which
an occurrence could trigger coverage under a Claims Made policy.
PRIOR CARRIER
INFORMATION
Eff-Exp Date One
Enter date: The effective date of the prior policy.
PRIOR CARRIER
INFORMATION
Eff-Exp Date One
Enter date: The expiration date of the previous coverage.
PRIOR CARRIER
INFORMATION
General Aggregate One
Enter limit: The liability aggregate limit amount.
PRIOR CARRIER
INFORMATION
Each Occurrence One
Enter limit: The liability each occurrence limit amount.
PRIOR CARRIER
INFORMATION
Carrier Two
Enter text: The name of the previous insurer.
PRIOR CARRIER
INFORMATION
Policy Number Two
Enter identifier: The policy number of the previous coverage.
PRIOR CARRIER
INFORMATION
Policy Type-Claims Made
(Checkbox) Two
Check the box (if applicable): Indicates the coverage trigger is on a claims-made basis
on a medical professional liability policy.
PRIOR CARRIER
INFORMATION
Policy Type-Occurrence
(Checkbox) Two
Check the box (if applicable): Indicates the coverage trigger is on an occurrence basis on
a medical professional liability policy.
PRIOR CARRIER
INFORMATION
Retro Date Two
Enter date: The retroactive date for the policy being described. This is the date for which
an occurrence could trigger coverage under a Claims Made policy.
PRIOR CARRIER
INFORMATION
Eff-Exp Date Two
Enter date: The effective date of the prior policy.
PRIOR CARRIER
INFORMATION
Eff-Exp Date Two
Enter date: The expiration date of the previous coverage.
PRIOR CARRIER
INFORMATION
General Aggregate Two
Enter limit: The liability aggregate limit amount.
PRIOR CARRIER
INFORMATION
Each Occurrence Two
Enter limit: The liability each occurrence limit amount.
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Section Name
Field Name
Field and/or Section Description
PRIOR CARRIER
INFORMATION
Carrier Three
Enter text: The name of the previous insurer.
PRIOR CARRIER
INFORMATION
Policy Number Three
Enter identifier: The policy number of the previous coverage.
PRIOR CARRIER
INFORMATION
Policy Type-Claims Made
(Checkbox) Three
Check the box (if applicable): Indicates the coverage trigger is on a claims-made basis
on a medical professional liability policy.
PRIOR CARRIER
INFORMATION
Policy Type-Occurrence
(Checkbox) Three
Check the box (if applicable): Indicates the coverage trigger is on an occurrence basis on
a medical professional liability policy.
PRIOR CARRIER
INFORMATION
Retro Date Three
Enter date: The retroactive date for the policy being described. This is the date for which
an occurrence could trigger coverage under a Claims Made policy.
PRIOR CARRIER
INFORMATION
Eff-Exp Date Three
Enter date: The effective date of the prior policy.
PRIOR CARRIER
INFORMATION
Eff-Exp Date Three
Enter date: The expiration date of the previous coverage.
PRIOR CARRIER
INFORMATION
General Aggregate Three
Enter limit: The liability aggregate limit amount.
PRIOR CARRIER
INFORMATION
Each Occurrence Three
Enter limit: The liability each occurrence limit amount.
PRIOR CARRIER
INFORMATION
Carrier Four
Enter text: The name of the previous insurer.
PRIOR CARRIER
INFORMATION
Policy Number Four
Enter identifier: The policy number of the previous coverage.
PRIOR CARRIER
INFORMATION
Policy Type-Claims Made
(Checkbox) Four
Check the box (if applicable): Indicates the coverage trigger is on a claims-made basis
on a medical professional liability policy.
PRIOR CARRIER
INFORMATION
Policy Type-Occurrence
(Checkbox) Four
Check the box (if applicable): Indicates the coverage trigger is on an occurrence basis on
a medical professional liability policy.
PRIOR CARRIER
INFORMATION
Retro Date Four
Enter date: The retroactive date for the policy being described. This is the date for which
an occurrence could trigger coverage under a Claims Made policy.
PRIOR CARRIER
INFORMATION
Eff-Exp Date Four
Enter date: The effective date of the prior policy.
PRIOR CARRIER
INFORMATION
Eff-Exp Date Four
Enter date: The expiration date of the previous coverage.
PRIOR CARRIER
INFORMATION
General Aggregate Four
Enter limit: The liability aggregate limit amount.
PRIOR CARRIER
INFORMATION
Each Occurrence Four
Enter limit: The liability each occurrence limit amount.
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
Have You Ever Been Insured By
Mutual Assurance Or Medical
Assurance For Professional
Liability?
Enter Y for a Yes response. Input N for No response. Indicates the answer to, Have
you ever been insured by mutual assurance or medical assurance for professional
liability?.
GENERAL INFORMATION
Policy Number
Enter identifier: The policy number of the previous coverage.
GENERAL INFORMATION
Previous Employer
Enter text: The employer name (business name if self-employed). As used here, this is the
previous employer name.
GENERAL INFORMATION
If professional liability coverage is
provided through your employer,
do you maintain a separate policy
for professional liability?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Do you maintain a separate policy for professional liability?.
GENERAL INFORMATION
Have You Ever Been Diagnosed
With Or Professionally Advised To
Seek Treatment For Alcohol/Drug
Abuse Or Addiction, Mental Illness
Or Chronic Physical Illness?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Have you ever been diagnosed with or professionally advised to seek treatment
for alcohol / drug abuse or addiction, mental illness or chronic physical illness?.
GENERAL INFORMATION
Have You Ever Been Diagnosed
With Or Professionally Advised To
Seek Treatment For Alcohol/Drug
Abuse Or Addiction, Mental Illness
Or Chronic Physical Illness? -
Remarks
Enter text: A statement explaining if you have ever been diagnosed with or professionally
advised to seek treatment for alcohol/drug abuse or addiction, mental illness or chronic
physical illness.
GENERAL INFORMATION
Have any fee or professional
relation complaints been
registered against you with your
professional association(s),
hospital(s) or any state licensing
authority?
Enter Y for a Yes response. Input N for No response. Indicates the answer to, Have
any fee or professional relation complaints been registered against you with your
professional association(s), hospital(s) or any state licensing authority?.
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
Have any fee or professional
relation complaints been
registered against you with your
professional association(s),
hospital(s) or any state licensing
authority? - Remarks
Enter text: An explanation of any fee or professional relation complaints that have been
registered against you with your professional association(s), hospital(s) or any state
licensing authority.
GENERAL INFORMATION
Have You Ever Been Charged With
Or Convicted Of A Criminal
Offense?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Have you ever been charged with or convicted of a criminal offense?.
GENERAL INFORMATION
Have You Ever Been Charged With
Or Convicted Of A Criminal
Offense? - Remarks
Enter text: A statement explaining if you have ever been charged or convicted with a
criminal offense.
GENERAL INFORMATION
Has Your Professional Liability
Insurance Ever Been Canceled,
Suspended, Non-Renewed,
Declined Or Issued Only On
Special Terms?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Has your professional liability insurance ever been cancelled, suspended, non-
renewed, declined or issued only on special terms?.
GENERAL INFORMATION
Has Your Professional Liability
Insurance Ever Been Canceled,
Suspended, Non-Renewed,
Declined Or Issued Only On
Special Terms? - Remarks
Enter text: A statement explaining if your professional liability insurance has ever been
canceled, suspended, non-renewed, declined or issued only on special terms.
GENERAL INFORMATION
Are You A Subsidiary Of Another
Entity Or Do You Have Any
Subsidiary?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are you a subsidiary of another entity or do you have any subsidiaries?.
GENERAL INFORMATION
Are You A Subsidiary Of Another
Entity Or Do You Have Any
Subsidiary? - Remarks
Enter text: A statement explaining if you are a subsidiary of another entity or have any
subsidiary.
REMARKS
Enter text: The medical professional liability insurance application general remarks.
ACORD 101, Additional Remarks Schedule, may be attached if more space is required.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
REMARKS
Enter text: The medical professional liability insurance application general remarks.
ACORD 101, Additional Remarks Schedule, may be attached if more space is required.
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Section Name
Field Name
Field and/or Section Description
SIGNATURE
Notice of Information Practices
(Privacy) checkbox
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices
(ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific
38s are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition,
ACORD 38 contains CA and MA state specific language.
SIGNATURE
Applicant's Initials
Initial here: The named insured's initials.
SIGNATURE
Producers Signature
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) of the company(ies) listed on the document. This is required in most
states.
SIGNATURE
Producer's Name
Enter text: The name of the authorized representative of the producer, agency and/or
broker that signed the form.
SIGNATURE
State Producer License No
Enter identifier: The State License Number of the producer.
SIGNATURE
Applicant Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National
Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer
state license number.
Edition
Date
The edition identifier of the form including the form number and edition (the date is typically
formatted YYYY/MM).
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