SUPPLEMENT
6
AUTHORIZATION FOR RELEASE OF PRIOR CARRIER'S LOSS EXPERIENCE
1.
Full name of Applicant:
2.
Mailing Address:
3.
Please provide the following information regarding the Applicant's professional liability insurance for the past five (5) years.
a)
Name of Carrier:
Policy number:
Policy Term/Limits and Deductible:
b)
Name of Carrier:
Policy number:
Policy Term/Limits and Deductible:
c)
Name of Carrier:
Policy number:
Policy Term/Limits and Deductible:
d)
Name of Carrier:
Policy number:
Policy Term/Limits and Deductible:
e)
Name of Carrier:
Policy number:
Policy Term/Limits and Deductible:
I hereby authorize the release of claims information from any prior carrier for the firm(s) named in question 1 above to:
Authorized Signature
Title
Date
