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State of West Virginia Recredentialing Form:  Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment.  (If more space is needed, please supply the information on a separate sheet and attach.)

Submit a copy of your current professional liability insurance coverage face sheet showing coverage in your practice specialty. Please list current and previous insurance carriers SINCE THE LAST CREDENTIALING DATE beginning with most current.  (If additional space is needed, please photocopy this page and attach.)

Current Insurance Carrier

Telephone Number

(   )    -

Address

City

State

Zip

Coverage Effective Date

Coverage Termination Date

Amount of Coverage

If Umbrella/Excess coverage, amount of coverage

$ million/occurrence

$ million/aggregate

$

Policy Number

Type of Coverage

Do you have prior acts coverage?

Claims Made Occurrence

No Yes

Previous Insurance Carrier

Telephone Number

(   )    -

Address

City

State

Zip

Coverage Effective Date

Coverage Termination Date

Amount of Coverage

If Umbrella/Excess coverage, amount of coverage

$ million/occurrence

$ million/aggregate

$

Policy Number

Type of Coverage

Do you have prior acts coverage?

Claims Made Occurrence

No Yes

Previous Insurance Carrier

Telephone Number

(   )    -

Address

City

State

Zip

Coverage Effective Date

Coverage Termination Date

Amount of Coverage

If Umbrella/Excess coverage, amount of coverage

$ million/occurrence

$ million/aggregate

$

Policy Number

Type of Coverage

Do you have prior acts coverage?

Claims Made Occurrence

No Yes

Previous Insurance Carrier

Telephone Number

(   )    -

Address

City

State

Zip

Coverage Effective Date

Coverage Termination Date

Amount of Coverage

If Umbrella/Excess coverage, amount of coverage

$ million/occurrence

$ million/aggregate

$

Policy Number

Type of Coverage

Do you have prior acts coverage?

Claims Made Occurrence

No Yes

12/02; 3/03; 11/03; 1/04; 5/04; 10/04     **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 14

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