THE UNIVERSITY OF ALABAMA AT BIRMINGHAM PROFESSIONAL LIABILITY TRUST FUND 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information. Fill in your last name, first name, and middle name clearly. Include your date of birth and department.
3. Indicate your employment status by selecting either full-time or part-time, and specify your classification as faculty, fellow, or resident.
4. Complete the claim information section. If you have had a malpractice claim filed against you, provide details on a separate sheet as instructed.
5. Answer the practice information questions with 'Yes' or 'No' regarding procedures you perform. Be sure to only answer 'Yes' for those procedures where you hold privileges.
6. Specify the effective date for your coverage and ensure that it aligns with your date of hire.
7. Finally, sign the application electronically by typing your name and include the date signed before submitting it to PLTF@UABMC.EDU.

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