Cna Form G 119639 A – Fill Out and Use This PDF

Cna Form G 119639 A PDF Details

The CNA HealthPro Medical Practitioners Application, form CNA G 119639 A, is used by physicians to apply for claims-made professional liability coverage. It collects personal details, practice addresses, and existing policy information from each applicant.

The form also requires medical education records, board certifications, and memberships in professional associations. Applicants must disclose any past legal or disciplinary incidents that could affect their eligibility to practice medicine.

What Information Does the CNA G 119639 A Form Require?

The application asks for the following categories of information:

• Personal data including full name, date of birth, Social Security number, and home address
• Professional credentials including National Provider Identifier (NPI) number, medical specialty, and active state licenses
• Practice information including office address, hours of operation, and names of professional partners
• Medical education history including medical school, residency, and fellowships with dates
• Board certifications and professional association memberships
• Full insurance history with prior carrier names, policy periods, and coverage limits
• Any pending or resolved legal claims or disciplinary actions

Who Should Complete the CNA G 119639 A Application?

Any physician or medical professional applying for claims-made malpractice coverage through CNA HealthPro must complete this application. It is also required for practitioners renewing an existing policy. Similar credentialing documents include the Idaho Practitioner Application, the Multi-Plan Practitioner Application, and the Uniform Healthcare Practitioner Credentialing Application.