I N S T R U C T I O N S
1. Complete and sign the application form. Each application has a Certification which must be executed before a notary public. If the application has an Authorization for Release of Information, it must be completed as well.
2. Provide a copy of your current professional liability insurance policy including the declarations page.
3. Obtain a copy of your loss history for the past five years from your current insurer and provide it to us along with your application.
4. Provide a copy of your curriculum vita.
Forward the above information to the following address:
Marsh, USA
Post Office Box 11850
Charleston, WV 25339Telephone numbers:
304-556-4810
800-597-4947
Contact information for the West Virginia Board of Risk and Insurance Management:
Telephone:
304-766-2646
800-345-4669Facsimile:
304-766-2653IF QUESTIONS ARISE DURING COMPLETION OF THE APPLICATION – PLEASE INQUIRE PRIOR TO SUBMISSION
