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 |
Disclaimer: The information provided contains confidential and proprietary information belonging exclusively to Conventus Inter-Insurance Exchange. The information is intended to provide you with answers to your general membership questions. However, for specific issues related to your individual or corporate professional liability insurance, please consult the original policy and all attached endorsements that you received from Conventus. For questions related to the operation of the Exchange, please send a written request for information stating your departure date from the Exchange. This FAQ information is not a contract and does not provide specific explanations concerning coverage with Conventus. Information contained in these FAQs is general in nature and not intended to respond to specific member questions.
