Professional Liability Action Explination Form



This form must be completed if you answered "yes" to question #1 on the Disclosure Questions. Please complete a form for each pending or settled professional liability action or any payment made on behalf of applicant. All questions must be answered completely.
 
Emplify Health | 1900 South Ave. - La Crosse, WI 54601 | (608) 782-7300 or (800) 362-9567