CONSULTANT APPLICATION

CONSULTANT APPLICATION

You have found the right page to start the process of becoming a Benchmark Consultant. The application process is quick and easy. Once you complete this form, it will be emailed directly to me, Kelly Denison. I will review the form and begin the process immediately. If you have any questions or would like me to assist you with this form, feel free to call me directly at (800) 458-1261.

Thank you,
Kelly

Consulting areas of interest

Personal Injury Medical Malpractice

Disability All areas

Workers' Comp

Consultant information

Name
Specialty
Sub-Specialty
License #	State	Exp. Date
Date of Birth	Tax ID or SS#
Mailing Address
Phone Number	Email
Contact Person	Email

What we need to get started

	Curriculum Vitae
	Professional liability insurance face sheet
	My professional liability insurance does not cover me for work outside my medical group. I would like information about how I could be added to Benchmark's medical-legal professional liability coverage for my consulting.

Step 1

A credentialing check will be performed.

Step 2

A Consultant Package will be mailed to you, to include, but not limited to:

    a) Letter of Agreement and Fee Schedule
    b) Consultant Questionnaire
    c) Obtain Appointment Schedule
    d) Schedule Consultant Orientation

Questions about this form? Call Kelly Denison at 800-458-1261