Applications for Medical Professional Liability Insurance
To apply for medical professional liability insurance coverage or renew a current policy with Conventus, please submit a completed application to conventus@conventusnj.com or contact a Conventus membership specialist.
Use the links below to select a paper-based or DocuSign application.

Automatic Withdrawal (ACH)
Name | Format | Download |
---|---|---|
Automatic Withdrawal (ACH) ACH PowerForm |
Download |
New Member Applications
Name | Format | Download |
---|---|---|
Physicians and Surgeons Professional Liability Insurance Physician Application PowerForm |
Download | |
Corporate Entity Corporate Entity PowerForm |
Download | |
Non-Physician Healthcare Provider Professional Liability Insurance Non-Physician PowerForm |
Download | |
Group Application Group Application PowerForm |
Download |
Renewal Applications
Name | Format | Download |
---|---|---|
Physician Renewal Physician Renewal Powerform |
Download | |
Corporate Entity Renewal Corporate Entity Renewal Powerform |
Download |
Supplemental Applications
Name | Format | Download |
---|---|---|
Locum Tenens | Download | |
Cosmetic Procedures | Download | |
Pain Management | Download | |
Physician Practice Location and Hours Update Physician Practice Location and Hours Update Powerform |
Download | |
Bariatric Supplemental Application Questions | Download | |
Part-Time Application Part-Time Application Powerform |
Download | |
Virtual Care Virtual Care PowerForm |
Download |
Power of Attorney
Name | Format | Download |
---|---|---|
Business Entity Policy Power of Attorney Power of Attorney PowerForm |
Download | |
Individual Policy Power of Attorney Power of Attorney PowerForm |
Download |
Loss History / Credentialing
Name | Format | Download |
---|---|---|
Loss History / Credentialing Release Form Loss History / Credentialing Release Powerform |
Download | |
CAQH Signature Form CAQH Signature Powerform |
Download |