Contact information, including your name, address, phone, etc.
Insurance Information (Click here to view the mandatory ACSLPA PLI requirements)
A payment of $40/month from the date of returning to active practice until the end of the year is required. At the end of this form payment will be required via Visa, Visa Debit or MasterCard.
Once your request has been processed you will be notified and will need to login to the online system again to update your employer information.