Top
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.
PDF/Download: You can download and complete the PDF forms linked below in Acrobat Reader. Please note the PDF forms are not fillable so you will need to print and fill them out.
Electronic signing (eSign): Some forms can be electronically signed and submitted using DocuSign®. Click the eSign link next to the form to get started. To learn more about DocuSign, please visit the DocuSign Troubleshooting FAQ.
Please note that after filling in your email, if you are not able to complete the DocuSign application in one session, you can save the application for later use. DocuSign allows you to securely save your progress so you can continue the process later.
Don’t see the form you need? Contact us, we can help.
Loss Run Direct Payment Authorization
| Name | Format | Download |
|---|---|---|
| Loss Run Direct Payment Authorization Loss Run Direct Payment Authorization eSign |
Download |
New Member Applications
| Name | Format | Download |
|---|---|---|
| Physicians and Surgeons Professional Liability Insurance Physician Application eSign |
Download | |
| Corporate Entity Corporate Entity eSign |
Download | |
| Non-Physician Healthcare Provider Professional Liability Insurance Non-Physician eSign |
Download | |
| Group Application Group Application eSign |
Download |
Renewal Applications
| Name | Format | Download |
|---|---|---|
| Physician Renewal Physician Renewal eSign |
Download | |
| Corporate Entity Renewal Corporate Entity Renewal eSign |
Download |
Supplemental Applications
| Name | Format | Download |
|---|---|---|
| Locum Tenens | Download | |
| Physician Practice Location and Hours Update Physician Practice Location and Hours Update eSign |
Download | |
| Bariatric Supplemental Application Questions | Download | |
| Part-Time Application Part-Time Application eSign |
Download | |
| Virtual Care Virtual Care eSign |
Download | |
| Plastic/Cosmetic and Medical Aesthetics Procedures Supplemental Application Plastic/Cosmetic and Medical Aesthetics Procedures eSign |
Download | |
| Pain Management Pain Management eSign |
Download |
Power of Attorney
| Name | Format | Download |
|---|---|---|
| Business Entity Policy Power of Attorney Power of Attorney eSign |
Download | |
| Individual Policy Power of Attorney Power of Attorney eSign |
Download |
Loss History / Credentialing
| Name | Format | Download |
|---|---|---|
| Loss History / Credentialing Release Form Loss History / Credentialing Release eSign |
Download | |
| CAQH Signature Form CAQH Signature eSign |
Download |
Disclaimer:
The online Practice Resources and Knowledge Center content and information, including but not limited to any materials relating to practice resources, practice management, practice management resources, risk management, patient safety or insurance regardless of where they are located on this website, are for educational purposes only. Materials provided on this website are intended solely to provide general information on a number of medical, legal, risk management, practice management, patient safety, practice resources and insurance issues. The Company takes reasonable efforts to provide accurate information but cannot guarantee its accuracy and does not represent that such information complies with or addresses all applicable local, state, or federal statutes, laws or regulations.
The Company disclaims liability arising from actions taken or not fully taken based on the content of this website permitted by law. Information provided herein is not intended to constitute medical, legal, insurance or other professional advice. Consult appropriate qualified professionals, including legal, medical, insurance, or other advisors, regarding your specific circumstances.
Although the Company makes reasonable efforts to provide accurate and reliable content, changes may be made to the information upon which the content is based. These changes may or may not be incorporated into the content of this website. The Company may amend the content of this website at any time, without notice. The Company may maintain archives of its previously published materials. Such materials may not be updated even if information changes. For example, content in newsletters, risk alerts, toolkits, forms, applications, or any other information on the website may not be updated as rules, regulations, laws or statutes change, or if customary practices change. Past results, examples, claim scenarios, or case studies described in any materials are illustrative only and do not guarantee similar outcomes. Nothing on this website creates a physician-patient, attorney-client, broker-client, insurer-insured, or other professional relationship. Users remain solely responsible for evaluating the suitability of any information, form, checklist, or recommendation before relying upon it.
