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Medical Professional Liability InsuranceClaimsMade Physician Application ProAssurance Indemnity Company, Inc. PO Box 150 Okemos, MI 488050150 800.282.6242 Fax 608.828.1100 With your fully completed,

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Written verification of form is a formal document that confirms the accuracy and completeness of information submitted in a particular form.

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The information that must be reported includes the names of the parties involved, the nature of the information being verified, signatures, and any relevant identifying numbers.

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