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0000443-0000001-0000044 1 marmoore_plsela-amna American Nurses Association ANA PROFESSIONAL LIABILITY INSURANCE APPLICATION SELF-EMPLOYED NURSE PROFESSIONALS HOW TO APPLY: 1. Complete application below. 2. Note the premium below for the policy you selected. All premiums are annual. 3. Return your completed application, along with your annual premium, to the address provided. All coverages elected must be under the same policy limits. Coverage is effective the date your application is approved and payment is received. Please allow three to four weeks for delivery of your certificate. Please print all information. Visit www.proliability.com for more information and to view available professions for applying online. FOR RESIDENTS OF LOUISIANA ONLY. NOTE: Nurse anesthetists and nurse midwives are not eligible for coverage. If you own a home health care or temporary staffing agency, you are not eligible for this program; please contact administrator for proper application. Receive a 10% Premium Credit! See if you qualify for one of these four ways to save. You will receive a 10% premium credit if you complete or participate in one of the following: 1. Attend an approved loss prevention/loss control/risk management seminar. The seminar must be at least four hours in length. The seminar credit will be on a per policy basis (one seminar, one credit, one annual policy period). 2. Hold any of the following certifications: ANCC, AOCN

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