CRSM Online Application

Thank you very much for applying for General/Professional Liability through your association as a CRSM member benefit .

Please note all members may not be eligible for this coverage.

Once your application has been completed and returned it will be submitted to an underwriter for review. Please take a moment to review the following description of operations listed hereunder which are used in determining primary eligibility for this program. If you have questions concerning whether your business practices meet these requirements please contact Ty Rainey at 918.794.3884 or ty@vaughanins.com.

Regulatory Compliance Consulting and Clinical or Site Management Organization: Strategic Planning-Recruitment and Assembly, Trial Management, Trial Monitoring, Data Management, Analysis and Reporting, Protocol Preparation and Facilities Assessment. All Consulting Professional Services provided are required to comply with all laws and regulations at a local, state and federal government level in accordance with any and all Federal Regulatory Compliance requirements.

If it is determined that your work is outside the acceptable criteria for this program, please be assured that we will make every effort to obtain the very best coverage at the most affordable price with an alternate insurance provider.

Once your application has been approved by the company you will be notified via email from Vaughan Insurance Group. Attached to this notification will be an invoice for the annual premium. As soon as payment has been received, you will be provided a policy binder for 60 days indicating your coverage has been bound pending receipt of your policy from the insurance company. Also, any certificate of insurance requests will be sent at this time.

To apply for General/Professional Liability please complete and submit the form below.

CRSM: Clinical Research Site Management

FOR MEMBERS applying for General/Professional Liability as a CRSM member benefit through THEIR association.
    *Please note that "Prior Acts" coverage is only available when your expiring policy is written on on a "claims made" form directly prior to purchasing this coverage. Coverage for "Prior Acts" will be provided for a (2) year term for a one time premium charge of 25% of the annual premium
  • Applicant Information Section

  • For "Other" please specify below.
  • ADDITIONAL INFORMATION
    If "yes,"please explain below.
  • Loss History

    If "Yes" please explain below
    If "yes" please enter all occurrences, reserves or claims for the prior 5 years.
  • Claim DateClaim DescriptionAmount Paid 
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  • Current Coverages

    If "Yes" please fill in spaces below.
  • Insurance Co.Effective Coverage DatePolicy# 
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    If "Yes" please fill in spaces below.
  • Insurance Co.Effective Coverage DatePolicy# 
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    To add more entries, click on the + sign at end of row #1
    If "Yes" please fill in spaces below.
  • Insurance Co.Effective Coverage DatePolicy# 
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    To add more entries, click on the + sign at end of row #1
    If "Yes" please fill in spaces below.
  • Insurance Co.Effective Coverage DatePolicy# 
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    To add more entries, click on the + sign at end of row #1
  • Coverage Eligibility Requirements

    NOTE: All of the below questions must be answered "Yes" to be eligible for coverage.
  • Anticipated # Trial Sites AnnuallyAnticipated # of Trials AnnuallyAre Subjects Required to Stay Overnight? 
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  • Please remit payments to:

    Vaughan Insurance Group, LLC
    P.O. Box 52534
    Tulsa, Ok 74152

    Thank you for allowing Vaughan Insurance Group to service your insurance needs. It has been a pleasure serving you. Should you have any additional questions, please contact Ty Rainey at (918) 794-3884 or ty@vaughanins.com.

    * INFORMATION CONTAINED HEREIN TO THE BEST OF MY KNOWLEDGE IS ACCURATE AND COMPLETE

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