Non-Standard Program
Please Include the following with your application:
1. Fully completed application, signed and dated
(Do not leave anything blank!)
2. Release, signed and dated
(this is part of the application)
3. Curriculum Vitae
4. Declaration page of current professional liability policy
5. Claims History including detailed information of allegations, disposition,
defense attorney, plaintiff ’s attorney and indemnity payment
(if applicable)
6. Copies of all current licenses