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Malpractice Insurance for medical students
Your information
Please enter your name as it appears in the passport. All fields are required. Incomplete applications may experience processing delays.
First Name
Middle Name
Last Name
Date of birth
Email address
Permanent home address
Street
City
State
Country
ZIP code/PIN code
Medical school you are currently attending
Expected graduation date
Elective information
Rotation start date
Rotation end date
Institution where your elective will take place
Institution address
Street
City
State
Country
ZIP code/PIN code
Elective coordinator name
Elective coordinator email address
Department supervising your clinical activities (Ex: Internal Medicine, Surgery, Pediatrics)
Course description of all clinical activities you will be performing
Will you be assisting in any surgical procedures?
If yes, list all procedures. If no, enter "N/A"
Will you be assisting in any obstetrical procedures?
If yes, list all procedures. If no, enter "N/A"
Additional information
Are you a member of an association?
What is your membership number?
How did you hear about the AMPI Medical Malpractice Insurance Program?
Type your signature
Date
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Note to Applicants
Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any material fact hereto, commits a fraudulent insurance act, which is a crime and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
This policy for which you are applying is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your State. State insurance insolvency guaranty funds are not available for your risk retention group.
Coverage is limited to activities and locations listed on the application for enrollment.



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