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Claims History Request from a Physician No Longer Insured by CRICO

Please complete this form. Upon submission, you will be directed to the payment page where you can remit the $25 claims history processing fee using PayPal.
* = required field

Identification Requirements for Claims History Request

Requirements for Claims History Requests
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Delivery & Support Information
Where should this information be sent?
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Enter if the recipient is not the physician.
For a copy as well, enter your email address in "Note to Underwriting" below.
Optional
Enter if the recipient is not the physician.
Enter the two letter state code.
If you have the contact's email, please include it in "Note to Underwriting."
Confirmation and Follow-Up
I acknowledge this statement to be true.
By checking the box, you are confirming that you are the former CRICO-insured provider. Further, you acknowledge that you have verified the recipient email address above.
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Optional. I.e., Include additional email recipients if you have this information.