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 RISK MANAGEMENT Schneider Reg, onal Medical Center Room 5076,5° Floor APPLICATION FOR MALPRACTICE INSURANCE MEMORANDUM TO: All Health Care Providers FRO VI: Territorial Office of Risk Management In ac:ordance with law, no license obtained by a health care provider to pr ictice in the territwy 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 !.r insurance pone) 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 coverall. If such proof is not furnished, you will automatically be coy( red by the Government'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 EFTA01111623 -2- NAME: SPE( IALITY: SOCIAL SECURITY NO.: MED [CAL LICENSE NO.: DENTAL LICENSE NO.: MAII,ING ADDRESS: DEA NO.: TELE. PHONE NO.: (H) (W) PLEA. SE NOTE THAT NO PHYSICIAN OR OTHER HEALTH CARE P ROVIDER WILI BE GRANTED MALPRACTICE COVERAGE UNDER THE SELF-INS URANCE RETINTION PROGRAM UNTIL THIS FORM IS COMPLETED AND RETURNED TO THE TERRITORIAL OFFICE OF RISK MANAGEMENT. Remit Payment to: Department of Health/GVI Mail a vlication and payment to: Department of Health Office of Risk Management 1303 Hospital Ground - Suite 10 St. Thomas, VI 00802 EFTA01111624