Client Request

Coverys provides loss histories and coverage verification for healthcare providers who are insured with us now or were in the past. Please complete the form below to make a request. Requests are processed in the order they are received.

By checking this box, I acknowledge and accept Coverys’ Terms & Conditions and, to the extent applicable, I certify under penalty of perjury that: (i) I am in possession of a valid, signed authorization from the healthcare provider who is the subject of this request to obtain the requested claims loss history; (ii) the authorization was executed within the past six (6) months; and (iii) I am authorized to make this request on the healthcare provider’s behalf. I agree to defend, indemnify, and hold Coverys harmless from any claims, demands, or liability arising from Coverys’ disclosure of claims loss history to me in reliance on this certification. I understand that Coverys may request proof of the signed authorization or proof of my legal authority to act on the healthcare provider’s behalf, and that failure to provide such proof may result in denial of this request.

I have reviewed and agree to Coverys’ processing of the personal information I have provided in accordance with Coverys’ Privacy Statement.

A $30 fee is charged for each CLH report processed for credentialing companies and hospitals. We will mail an invoice to the requestor (please do not send prepayment).

At Least Two Required

Or Select number of years below