BIM Form | American Academy of Insurance Medicine

APPLICATION FOR ACCEPTED CANDIDATE STATUS

Full Name(Required)

Email(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

Education :

College

Name of Institution, Location(Required)

Dates Attended(Required)

Degree(Required)

Medical School

Name of Institution, Location(Required)

Dates Attended(Required)

Degree(Required)

Postdoctoral Training :

Internship

Name of Institution, Location

Type of Program/Field of Practice

Residency

Name of Institution, Location

Type of Program/Field of Practice

Fellowship

Name of Institution, Location

Type of Program/Field of Practice

Licensure

Licensed to practice in state(s), province(s), or country of:

Jurisdiction(Required)

Date Licensed(Required)

License Number(Required)

Upload License(Required)

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 512 MB.

Enclose a copy of your current, valid medical license from the state or province where you practice insurance medicine

Certification by National Board of Medical Examiners, Federal Licensing Examination (FLEX) or Medical Council of Canada:

Date

Certification Number

If certified by any of the American or Canadian specialty boards:

Name of Board

Date of Certification

Medical Society Memberships:

Name of Society

Dates

Insurance Medicine Experience:

Name of Insurance Company(Required)

Position(Required)

Hours per Week(Required)

Dates(Required)

Has any disciplinary action been taken against you in the last ten years by any governmental authority, health care facility, or professional association?(Required)

YES

Has your medical license or specialty Board certification ever been denied, suspended, or revoked for any reason?(Required)

YES

Please explain on separate sheet if above questions are answered in affirmative.

I hereby make application to the Board of Insurance Medicine for the issuance to me of a certificate of qualification as a specialist in Insurance Medicine and for examination relative thereto, all in accordance with and subject to the rules and regulations of the Board. Upon the issuance of the certificate, I agree to and do become bound by the constitution and bylaws of the Board of Insurance Medicine insofar as applicable. I agree to disqualification from examination or from the issuance of a certificate of qualification or to forfeiture and return to the Board of such certificate of qualification in the event that any of the rules and qualifications set forth in the by-laws have been or shall be violated by me. I agree to hold said Board of Insurance Medicine, its members, examiners, officers and agents free from any damage or claim for damage or complaint by reason of any action they or any of them may take in connection with this application any examination or failure of said Board of issue to me such certificate of qualification.

Signature of Applicant(Required)

Date(Required)

Application fee is $255 payable by Credit Card. After you click Submit Application you will be redirected to the payment page.