Allied Health Care Miscellaneous Supplement

Allied Health Care Miscellaneous Supplement APP PDF Download

Allied Health Care - Miscellaneous Supplement

  • Complete the following only for the professions for which you are applying for coverage. Professions not listed here may require a separate supplemental application

  • A. Dental Assitant

  • B. Dental Hygienist

  • C. EEG Technician/Technologist

  • D. First Aid/CPR Training

  • E. Health Educator

  • F. Lactation Consultant

  • G. Medical Office Assistant

  • H. Opticians & Optometric Assistants

  • I. Patient Intake Technician

  • J. Speech Language Pathologist

  • This supplemental application is incorporated into and is deemed a apart of the other application(s) submitted in connection with the requested insurance. Any and all notices and representations included in such other application(s) are incorporated by reference in this supplemental application as though fully set forth herein.

  • (Please type full name in space provided)
  • Principal, Partner or Officer

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  • (Required in New Hampshire)

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