Volunteer Malpractice Insurance Form
Please complete this form to apply for volunteer malpractice insurance coverage. All information provided will be used solely for insurance purposes.
Full Name
*
First Name
Last Name
Organization or Affiliate Name
*
Role or Position
*
Primary Service Type
*
Please Select
Health outreach
Education/tutoring
Community support
Disaster relief
Food distribution
Other
State or Region of Service
*
Service Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Estimated Weekly Volunteer Hours
*
Have you had any prior malpractice claims as a volunteer?
*
No
Yes
Briefly describe your volunteer duties
*
Submit Application
Should be Empty: