Application for Lab Directors » Sallop Insurance Inc.

First Name*

Last Name*

Company Name

Address*

City*

State*

Zip Code*

Website

Email*

Are you a member of AAB?*

Where are you contracted or practicing?*

Name and location of each facility:*

Facility 2:

Facility 3:

Do you rent office space?*

Do any states in which you work require lincensure? **

If yes, please list states:*

Annual Revenue / Salary?*

(Please enter a number, no dollar sign.)

Previous insurance (if applicable)

Have you been involved in any claims?*

If yes, please explain:*

Are you the Lab Director of a facility that is involved in Reproductive Medicine?*

Do you provide virtual care?*

If yes, how much of your work is "Hands On"?*

Please provide the percentage. (Please enter a number, no percent sign.)

Please upload your CV here*

(PDF or Word)

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Max. file size: 6 MB.

Additional Comments

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FRAUD WARNINGS:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties.

(Not applicable in AL, AR, CO, DC, FL, KY, KS, LA, ME, MD, NJ, NM, NY, OH, OK, OR, PA, RI, TN, VA, WA and WV).

Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

*Applies in MD only.

APPLICABLE IN CO

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

APPLICABLE IN FL AND OK

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*.

*Applies in FL only.

Sallop Insurance Application for Lab Directors

FRAUD WARNINGS:

APPLICABLE IN CO

APPLICABLE IN FL AND OK