PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR
INDIVIDUAL ALLIED HEALTHCARE PROFESSIONALS
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Billing Information
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 occupations for which you are requesting coverage. If you are a student, and do not currently hold a healthcare license or certification, please select your primary area of study.
Licensed or Certified Professional Counselor
Mental Health Counselor
Pastoral Counseling Assistant
Pastoral Counselor
Requested Effective Date of Coverage:
Application # 9402740