When this form may help
Use this form to describe professional services, staffing, credentials, patient population, procedures, locations, risk controls, and claims history. Do not place patient health information in the public form URL or other public query strings.
Authority boundary: This Hedge form is a submission-preparation resource. It is not a quote, binder, coverage commitment, market-access statement, or instruction to release a risk to a carrier.
Topics covered
- professional services
- staffing
- credentials
- patient population
- risk controls
Before you send it
Complete the form with current facts from the insured. Confirm the named insured, operations, locations, requested coverage, effective date, and loss information. Include the primary application, loss runs, schedules, and other documents that apply to the account. Hedge will identify any additional market-specific requirements after review.
Download the fillable PDF
This file is published by Hedge and can be completed in a PDF editor. Review every answer before attaching it to a submission.
Download Hedge Allied Health and Medical Professional Supplemental