Renewal Application

Renewal Application & Contact Update Form
Please provide the following phone numbers:
If yes, please describe on Notes page that follows.
If yes, please describe on Notes page that follows.
If yes, please describe on Notes page that follows.
If yes, please complete Form G.
If yes, please complete Form F.
If yes, please describe on the Notes page that follows.
If yes, please complete Form A.

Please note that Physicians Standard Insurance Company offers online Risk Management courses which may entitle you to a premium discount and CME credits.
PLEASE FAX THIS FORM ALONG WITH ANY NOTES AND/OR ADDITIONAL FORMS TO PHYSICIANS STANDARD INSURANCE COMPANY AT:
314-587-8001

IF YOU ANSWERED YES TO QUESTION #1:

Has your practice (group or individual) changed or made plans to change, since your last renewal?

IF YOU ANSWERED YES TO QUESTION #2:

Have you added any medical related equipment to your practice, or, are you sharing any medical equipment with others since your last renewal?

IF YOU ANSWERED YES TO QUESTION #3:

Have you started or stopped performing any procedures since your last renewal?

IF YOU ANSWERED YES TO QUESTION #6:

Have any physicians, ANPS, NPs, or PAs left your employment?


CONTACT UPDATE FORM

PRACTICE INFORMATION

Office Hours
:
:
Primary Office Address:
City
State/Province
Zip/Postal

PERSONAL INFORMATION

Home Address
City
State/Province
Zip/Postal

CERTIFICATES OF INSURANCE

Please provide Certificates of Insurance to the following institutions. (Attach separate page if necessary.)
Drop a file here or click to upload Choose File
Maximum upload size: 52.43MB

ANCILLARY PERSONNEL

The following ancillary personnel are part of this practice and require proof of coverage. (Attach separate page if necessary.)
Drop a file here or click to upload Choose File
Maximum upload size: 52.43MB

ADDITIONAL LOCATIONS

Office Hours
:
:
Address:
City
State/Province
Zip/Postal

Office Hours
:
:
Address:
City
State/Province
Zip/Postal