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For your convenience, we have provided some of our most requested applications here for your use. Please print the related application, complete it (applications can not be completed online) and return it by fax to (785) 233-8551. If you have questions or need further assistance, please contact us at (785) 233-7436 or e-mail Lorri Dean at ldean@khsc.org.
PHYSICIAN APPLICATIONS
MEDICAL ASSURANCE:
Both applications below are required for the Medical Assurance, Kansas physician application.
Application for Professional Liability Insurance for Physicians and Surgeons
 M A phy app 1.doc
Supplemental Claim Information Form
M A phy app 2.doc
The application below is required for the Medical Assurance, Missouri physician application.
M A MO phy app 1.doc
M A Professional Liability Renewal Application.doc
INTERMED:
Intermed New Physician Application
 IntermedNewPhysicianApp
Intermed Renewal Physician Application
IntermedRenewalApp
MEDICAL PROTECTIVE:
Physician Individual Professional Liability Insurance Application
GEMP Phys Indiv.pdf
Physician Entity Professional Liability Insurance Application
GEMP Phys Entity.pdf
PIC WISCONSIN:
Only for physicians who are employees of PIC Wisconsin insured hospitals.
Physicians
KANSAS HEALTH CARE PROVIDER
INSURANCE AVAILABILITY PLAN:
To get coverage through the "Plan," you must have an active Kansas license, submit a completed application and supply a deposit check for a minimum of $500 (made payable to: Kansas Health Care Provider Insurance Availability Plan) PRIOR to the effective date.
Physician Application
HOSPITAL APPLICATIONS
PIC WISCONSIN:
Facilities Info Sheet
Facility General Liability
Facility Professional Liability
Facilities Umbrella (Optional)
MEDICAL ASSURANCE:
Health Care Facility Application
Health Care Facility Supplement
Non-Hospital Health Care Facility Application
TRAVELERS INDEMNITY COMPANY:
Business Income Worksheet
DIRECTORS AND OFFICER LIABILITY APPLICATIONS:
For current KHSC Directors and Officers' clients, please use the renewal application. All others use the new business application.
Renewal Application
New Business Application
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