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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.)

ADDENDUM

VERIFICATION OF PROFESSIONAL LIABILITY

I, the undersigned, authorize my CURRENT professional liability insurance carrier,

(Enter Current Professional Liability Insurance Carrier Name)

(Enter Street Address)(City)(State & Zip)

to send verification of my professional liability coverage, to include dates of coverage, amounts of coverage, and any limitations in

coverage, to    .

(Entity Specific)

  is to hereinafter be

(Entity Specific)

a Certificate Holder and is to be notified of the amount of my coverage and any future changes in my insurance status, to include all information regarding claims history (but not necessarily limited to judgments entered, claims settled, cases and lawsuits pending) and any restriction regarding specific privileges which may be excluded from coverage.

I will notify   of any

(Entity Specific)

changes in Professional Liability carriers so that another Verification of Professional Liability form can be completed.

________________________________________________________________________________________

Practitioner’s SignatureDate

Printed Name

Policy Number

(Instructions:  Please complete, sign, date and return to entity named above with your initial application.)

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 23

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