Professional Liability Division
The Professional Liability Insurance Enrollment form can be obtained here.
Please print this form and submit it to our office with the necessary paperwork attached to complete the enrollment process. After the enrollment process is completed, a copy will be returned to your department.
Instructions for completing the professional liability insurance enrollment forms:
Please type or print form.
The following fields are mandatory and must be filled out: last name, first name, social security #, Tx. license # or institutional permit, account #, department, location, faculty/resident, effective date, risk class (see Risk Class Chart below), enrollment status and department chair signature. Incomplete forms will be returned to the department.
If a temporary license number must be used, please submit a copy of the temporary license with the enrollment form.
Check the appropriate box for either enrollment, change in status, or resignation. These changes are not effective until this form is received by the Professional Liability Division.
Include a copy of the Personnel Action Form (PAF) when enrolling or changing enrollment status of a faculty/staff physician.
Please submit completed form to: firstname.lastname@example.org.
For questions regarding enrollment in the Professional Liability Insurance Plan or questions regarding risk class, please contact:
For specific questions regarding risk class or premiums, contact Office of General Counsel, Professional Liability Division, 3601 4th Street, Suite 2B137, MS 6237, Lubbock, Texas 79430, (806) 743-9921 or email@example.com.
Risk Class Chart
RISK CLASS I
- Dermatology (excluding X-Ray therapy, chemosurgery, or hair transplants)
- Family/General Practice (excluding deliveries, ANY surgery, general anesthesia, spinal blocks or caudals)
- Infertility (excluding ANY Ob/Gyn practice)
- Internal Medicine (excluding combined program with Pediatrics and sub-specialties)
- Pediatrics (excluding circumcisions, neonatology, and combined programs)
- Preventive Medicine
- Prison Practice (including minor surgery, but excluding general anesthesia, spinals, saddle blocks or caudals)
- Proctology (examinations only)
- Psychiatry (excluding shock therapy)
- Radiology (excluding catheterization)
RISK CLASS II
- Dermatology (including X-Ray therapy but excluding chemosurgery or hair transplants)
- Family/General Practice (including minor surgery, D&C’s and infant circumcisions, or assisting in minor surgery, but excluding general anesthesia, spinal, saddle blocks, or caudals)
- Gastroenterology (including minor surgery or assisting in major surgery on own patients)
- Gynecology (office practice w/o surgeries or OB care)
- Internal Medicine (including Endocrinology, Infectious Disease, Nephrology, Oncology/Hematology, Pulmonology, and Rheumatology)
- Internal Medicine/Pediatrics Residency (when combined with Pediatrics as Med-Pedi residency)
- Ophthalmology (excluding Lasik/PRK)
- Pediatrics (including infant circumcisions and combined Internal Medicine program; excluding neonatology and surgical procedures)
- Psychiatry (including shock therapy)
- Transitional Residency
RISK CLASS III
- Cardiology/Cardiovascular Disease (excluding invasive procedures)
- Critical Care
- Family/General Practice (including normal deliveries w/o anesthesia)
- Ophthalmology (including Laski/PRK surgery)
- Radiology (including catheterizations)
RISK CLASS IV
- Anesthesiology/Pain Management
- Cardiology (including invasive procedures)
- Cardiovascular Surgery/Thoracic Surgery/Vascular Surgery
- Emergency Medicine
- Family/General Practice (including surgery & deliveries with general anesthesia, spinals, saddle blocks, or caudals)
- General Surgery (including gynecological surgery w/o deliveries)
- Neurointerventional Surgery
- Oral Surgery
- Otolaryngology (excluding Plastic Surgery)
- Prison Practice (including surgery with general anesthesia, spinals, saddle blocks, or caudals)
RISK CLASS V
- Bariatric Surgery
- Dermatology (including chemosurgery or hair transplants)
- Family/General Practice (including deliveries/OB care and consisting of 50% or more of practice as OB)
- Neurological Surgery
- Obstetrics and Gynecology
- Orthopaedic Surgery
- Otolaryngology (including Plastic Surgery)
- Plastic Surgery