Professional Liability Insurance Reinstatement Application
Applicant Information
Full Name
Date of Birth
Business Name
Business Address
Phone Number
Email Address
Policy Information
Previous Policy Number
Date of Expiration
Reason for Lapse in Coverage
Professional Activities
Describe Professional Services Provided
Years in Practice
States of Operation
Claims History
Have there been any professional liability claims or incidents since the policy lapsed?
Yes
No
If yes, please provide details
Applicant Declaration
I certify that the information provided in this application is correct to the best of my knowledge.