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MedMal
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Please select any of the Facility Types that are applicable to the exposures you are reporting in this application:
Does this application include information for a Hospital or Medical Center?
Does this application include information for a Public Health Clinic or are Public Health Services provided?
Does this application include information for a Mental Health Clinic or are Mental Health services provided?
Does this application include information for a Jail, Juvenile Hall, or other Correctional Care Facilities?
Does this application include information for a School or provide Student Care Services?
Please check all the Facility Sub-Types that apply to the exposures you are reporting in this application:
General Hospital
Teaching Hospital
Medical School
Critical Access Hospital (CAH)
Children's Hospital
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Psychiatric Hospital
Acute Psychiatric Hospital (APH)
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Long Term Care Facility (LTC)
Hospital Based Clinics
Ambulatory Surgery Center
Jail
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Please check all the Accreditations, Licenses, and Memberships that apply to the Facilities you are reporting in this application:
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If the prior employee total differs from the amount provided previously by more than 10%, please provide reasons for the change.
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As the prior average daily attendance differs from the amount provided previously by more than 10%, please provide reasons for the change
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Aircraft Operation (7424)(1)
Airport Law Enforcement Officers (7720)
Airport Operator (7429)
Animal Control Officers (7720)
Bus Operators (7382)
Clerical Office (8810)
Clerical Telecommuting Employees (8871)
County Probation Officers, Group Counselors, or Juvenile Services Officers (9410)
District Attorney Inspectors (9410)
Electrical Light or Power Line Construction (7538)
Electrical Light or Power Companies (7539)
Firefighters - Regular (7706)
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Hospitals - veterinary (8831)(1)
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Medical Center Employees (8834)
Municipal - Non-Manual Labor (9410)
Municipal - Manual Labor (9420)
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