APPLICATION FOR NURSES PROFESSIONAL LIABILITY
Lockton Affinity, LLC | P.O. Box 410679 Kansas City, MO 64141-0679 | Lockton_info@locktonaffinity.com
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Purchase & Acknowledge
Select your status as a healthcare professional:
(you provide services on behalf of an entity you do not own, and receive a W-2 form from your employer)
(you provide services as an independent contractor and pay self-employment taxes using a 1099 form)
(you are a first-time student who does not currently hold a healthcare license or certification)
Please select the healthcare profession for which you hold the highest credentials or standards appropriate, as mandated by your state statutory guidelines.
Licensed Practical Nurse
Licensed Vocational Nurse
Nurse Practitioner - Acute Critical Care
Nurse Practitioner - Adult
Nurse Practitioner - Correctional/Jail
Nurse Practitioner - Emergency Room
Nurse Practitioner - Family Planning GYN only
Nurse Practitioner - Family Practice
Nurse Practitioner - Geriatrics
Nurse Practitioner - Neonatal
Nurse Practitioner - Pediatrics
Nurse Practitioner - Psychiatric
Nurse Practitioner - OB
Nurse Practitioner - School Nurse
Coverage is not available for Certified Registered Nurse Anesthetists or Midwives
Do you work more than 24 hours per week?
Did you graduate within the last 24 months?
Do you work in a nursing home, assisted living facility or similar setting?
Do you perform any cosmetic procedures?
What is the zip code where you predominantly practice or attend school?
Requested Effective Date of Coverage:
Application # 4791799