ALLIED HEALTHCARE PROFESSIONALS APPLICATION FOR PROFESSIONAL LIABILITY COVERAGE

ENCLOSED ARE THE FORMS NECESSARY FOR

THE ALLIED HEALTHCARE PROFESSIONALS APPLICATION

Thank you for choosing to apply with LONE STAR ALLIANCE, INC., A RISK RETENTION GROUP (LSA). We know that you have choices when purchasing liability insurance to protect your reputation and your medical practice. We appreciate the opportunity to earn your business.

When submitting your application, please:

Complete and sign the application.
Complete the Claim/Suit Information Addendum if a professional liability claim or suit has ever been brought against you.
Enclose the following:

A copy of your current declarations page

Drag files here or use the button below. Remove File

Select File

Current loss run(s) for a five-year period

Drag files here or use the button below. Remove File

Select File

A copy of active training certificates or licensures

Drag files here or use the button below. Remove File

Select Files

Any additional documentation requested in the application

Drag files here or use the button below. Remove File

Select Files

We want to make your application experience as simple as possible. If you have any questions during the process, we will be happy to assist you. Call 1-844-595-8866 and ask for Underwriting or visit our website at https://www.lonestara.com/resources/frequently-asked-questions-2

Payment Options

Which billing and payment option is right for you?

Billing email address

There are no finance charges or transaction fees associated with LSA payment plans. You can set up recurring automatic payments once your policy is issued by contacting Customer Service at 1-844-595-8866 ext. 5050 for assistance.