PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR
INDIVIDUAL ALLIED HEALTHCARE PROFESSIONALS
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Purchase Confirmation
Select your status as an allied healthcare professional:
If you are both employed & self-employed, please select self-employed as your status
Employed
(you provide services on behalf of an entity you do not own, and receive a W-2 form from your employer)
Self-Employed
(you provide services as an independent contractor, and pay self-employment taxes using a 1099 form)
Student
(you are a student who does not currently hold a license or certification and are not currently practicing in the profession for which you are seeking coverage)
State of Residence:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
How many hours do you work per week?
How many years experience do you have relevant to your profession?
Less than 1 year
Greater than 1 year, less than two years
Greater than 2 years, less than three years
Greater than three years
Please select all NBCC certifications that you currently hold:
Certified Clinical Mental Health Counselor (CCMHC)
Master Addictions Counselor (MAC)
National Certified Career Counselor (NCCC)
National Certified Counselor (NCC)
National Certified Gerontological Counselor (NCGC)
National Certified School Counselor (NCSC)
Requested Effective Date of Coverage:
Application # 10675607