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Certification of Professional Insurance
Complete this form in accordance with
Step Three: Fieldwork Documentation
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Student's Information
Student's Name
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Student's Email
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Student Program
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Site Name
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Supervisor/Site Administrator Information
Supervisor/Site Administrator Name
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Supervisor Email
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Name of Insurance Company
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Current Mailing Address
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Country
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Policy Number
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Policy Limits (Amount of Coverage)
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Policy Period (Start Date)
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Policy Period (End Date)
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Please select the appropriate option:
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Please select the appropriate option:
FACE SHEET FROM SITE PROFESSIONAL LIABILITY INSURANCE: I am submitting the face sheet from the professional liability insurance policy of the internship site at which I work. The site carries its own professional liability insurance in the type and amount noted above, which is adequate to cover the work I will perform at the site. OR
FACE SHEET FROM STUDENT'S MALPRACTICE INSURANCE: I am submitting the face sheet from my own malpractice insurance policy which will provide adequate coverage for the work I will perform during my fieldwork. My signature on this form indicates my agreement to keep this policy in force throughout the time I am actively engaged in doing clinical work. OR
[Alternative Fieldwork Only] FACE SHEET FROM STUDENT'S LIABILITY INSURANCE: I am submitting the face sheet from my own liability insurance policy which will provide adequate coverage for the work I will perform during my fieldwork. My signature on this form indicates my agreement to keep this policy in force throughout the time I am actively engaged at this fieldwork site.
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