CBS Malpractice
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Contact Information
Name
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Phone
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Practice Information
Is your Chiropractic License Active?
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Practice Address
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City
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State
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Zip
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Are you:
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Full Time
Part Time (20 hours or less)
How many patients do you see per week?
Has a malpractice claim or a board dispute ever been filed against you or your associates?
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Insurance Information
Current Malpractice Carrier
OR
No Insurance
Renewal Date
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Current Premium
Type of policy interested in
Claims Made
Occurrence
Policy Limits
Select One
$100K/$300K
$200K/$600K
$500K/$1.5M
$1M/$3M
$2M/$4M
Retroactive Date (if claims-made policy)
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