Professional Liability
Application & Forms

The following documents are in Acrobat™ format.  You will need the free Acrobat Reader to access these documents.  Click here for instructions and link to download Adobe Acrobat Reader.

• Professional Liability Application

  • Prior Acts Questionnaire
     

  • Download & print Form A if you have any Claims or Incidents.

     Form A -- Supplement to Application - Claim/Incident Report

   

  • A current claim history from your present carrier is REQUIRED with your application.
     

  • CURRENT NPDB Self-Query REQUIRED from all new applicants! Click Here.

   

• Ancillary Application

  • Form A -- Supplement to Application - Claim/Incident Report

• Locum Tenens Application

  • Form A -- Supplement to Application - Claim/Incident Report

• Form B -- Supplement to Application - Family Practitioners/General Practitioners Doing Obstetrics

• Form C -- Supplement to Application - Request for Part-Time Status

• Form D -- Supplement to Application - Anesthesiologists

• Aesthetic Laser/Light Technology Checklist

Phone: 503-371-8228 or 1-800-243-3503
Email info@npictdc.com
Northwest Physicians Insurance Company Copyright (c) 1998
2965 Ryan Drive S.E., Salem, Oregon 97301