GOVERNMENT OF

GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES . 0 - DEPARTMENT OF HEALTH 1303 HOSPITAL GROUND, SUITE 10, ST. THOMAS, U.S.V.I. 00802 OFFICE OF RI SK MANAGEMENT (340) 776-7849 Schneider Regional Medical Center (340) 774-7477, ex 5064 & 5076 Room 5076, 5° Floor (340) 7774001(FA X) APPLICATION FOR MALPRACTICE INSURANCE MEMORANDUM TO: All Health Care Providers FRO VI: Territorial Office of Risk Management In accordance with law, no license obtained by a health care provider to pr tctice in the terriOry shall be effective until said provider is covered by the group malpractice insurance policy procured by the Government of the Virgin Islands or any oth :a. insurance peak} providing coverage of not less than $250,000.00 for each patient involved in an occurrence. Pleas' indicate by checking below whether or not you desire malpractice coverage under the virgin Islands Government policy. If you do not. please provide proof of other coverage. If such proof is not furnished, you will automatically be coy( red by the Govei nment's policy and will be billed therefore. I would like coverage with the Virgin Islands Government policy I would like to renew my virgin Islands Government policy I do not wish to be covered by the Virgin Islands Government policy Enclosed is proof of other coverage lam: Engaged in private practice only Government employed with private practice Government employed with no private practice EFTA00601522