Office of Risk Management

Request for Proof of Medical Professional Liability Coverage

If you have questions, please contact Office of Risk Management: Phone: 217-333-3113, E-mail: UnivRiskMgmt@uillinois.edu.

* - Required fields

Medical Professional Information:

Last Name:*

First Name:*

Title:*

M.D. Ph.D. D.O. Other

D.O.B:*

ex: 07/15/2014

UIN:

Dates of Coverage:

From:
ex: 07/15/2014

to:
ex: 07/31/2014 or present

Claims History: (We will provide claims history for the 10 most recent years of employment.)

If claims history is required, please check box and upload signature of release or authorization (a document provided by the outside entity credentialing the medical professional above) in the 'Additional Information' section at the bottom of this request form.
We will not process Claims History without authorization. (Claim = a demand or suit seeking monetary damages)

Department Name:

M/C:

Mail Code ex. 078

Department Contact:

Phone:

ex. 555-123-4444

Fax:

ex. 555-123-4444

Email:

Certificate Holder Information: The certificate holder is the entity that is requesting proof of coverage from the University of Illinois.
It is the facility where you have applied for privileges and/or appointment.

Entity/Facility Name:*

Department Name:

Contact Name:

Address:*

Street Name

City Name

State

Zip Code

Phone:

ex. 555-123-4444

Fax:

ex. 555-123-4444

Email:

Person completing this form:

Contact Name:*

Address:*

Street Name

City Name

State

Zip Code

Phone:*

ex. 555-123-4444

Fax:

ex. 555-123-4444

Email:

Certificate Delivery Method(s):*

Send Certificate Directly to Facility by:

Fax E-mail

Send Copy to 'Person completing this form' by:

Fax E-mail

Additional Information: Additional Information:

Attach a Document:

First Choose File then click 'Attach Doc' to completely upload your file.

Choose a File:

There are no documents to delete

Please wait while we process your request.