A medical professional liability application identified in the ACORD index. Current markets may use newer carrier or program applications, so the intended market must confirm the acceptable form and edition.
Need this form? Send a quick request and we will help you get the right edition. You can also use the ACORD Forms Portal.
The edition shown is the edition observed in the official index on the review date. Confirm the acceptable edition, jurisdiction, and related forms with the intended market. Hedge links to ACORD's licensed download source and does not host or redistribute the ACORD file.
These relationships help assemble a coherent packet. They do not mean every related form is required for every account.
The applicant-information foundation for a commercial insurance submission. It organizes the named insured, business operations, locations, prior coverage, requested lines, and other account-level facts that line-specific sections build on.
Read the ACORD 125 guide →A request form for claims history or loss runs. The resulting carrier-issued loss information, valuation date, coverage period, and open-claim detail matter more than the request form by itself.
Read the ACORD 611 guide →These fillable Hedge resources can support preparation but do not replace a required ACORD or market-specific application.
A fillable Hedge supplemental for allied health and medical professional liability risks.
View form and fillable PDF →A fillable Hedge supplement for organizing prior losses, claims, and open-claim detail for wholesale review.
View form and fillable PDF →Request ACORD 196 from Hedge for help identifying the current edition and an authorized access path, or use ACORD's official Forms Portal. Hedge does not host or redistribute the ACORD PDF.
Professional services and procedures; Provider credentials and specialties; Patient population and locations; Staffing and supervision; Prior claims and known incidents.
No. That is the edition observed in ACORD's index on the source-review date. Confirm the edition, jurisdiction, related forms, and any market-specific application before releasing the packet.
Use the official source to confirm form availability, edition, jurisdiction, licensing, and related-form information.
Open official source →Use the official source to confirm form availability, edition, jurisdiction, licensing, and related-form information.
Open official source →Use the official source to confirm form availability, edition, jurisdiction, licensing, and related-form information.
Open official source →Use the official source to confirm form availability, edition, jurisdiction, licensing, and related-form information.
Open official source →Use the class submission guide to identify the underwriting facts and Hedge forms that may apply, then have Hedge confirm the intended market and route.