John L. Wortham & Son, L.P.

REQUEST TO COLLECT UNDERWRITING INFORMATION for MEDICARE REPORTING & SECONDARY PAYER ACT LIABILITY

YOU ARE APPLYING FOR A MODIFIED CLAIMS MADE LIABILITY POLICY WITH DEFENSE EXPENSE INCLUDED WITHIN THE LIMIT OF LIABILITY

Named Insured(s):

Street Address:

City:

State:

Zip Code:

Desired Policy Period:

Your Contact Person(s) For Underwriting Information:

Type of Entity:

For-Profit Not-For-Profit Taxable Non-Taxable

Organizational Type:

Individual Partnership Corporation Limited Liability Company
Public Private Joint Venture, Ownership

Describe your business products & operation:

Your Internet Website:

Your Estimated Number of Claims Reportable to CMS:

or Unknown at this time