Form 6 "Documentation of Professional Liability Insurance" - New York

What Is Form 6?

This is a legal form that was released by the New York State Department of Environmental Conservation - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the New York State Department of Environmental Conservation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 6 by clicking the link below or browse more documents and templates provided by the New York State Department of Environmental Conservation.

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Download Form 6 "Documentation of Professional Liability Insurance" - New York

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Form 6: Documentation of Professional Liability Insurance
Provide documentation in the fields below of professional liability insurance held by the
Applicant in an amount not less than one million ($1,000,000) U.S. dollars. Attach a copy of the
insurance certificate and other documentation as may be required to document the relationship
between a related entity that holds the insurance and the Applicant. The attachment(s) must
include a header that identifies it as an attachment to Form 6.
Name of Insurer:
Policy Number:
Amount of Coverage (US$):
Policy Expiry Date:
Deductibles (if any):
Exclusions (if any):
Name of the entity under
which the insurance is held:
If the insurance coverage is
held under the name of a
related entity, describe the
financial relationship
between the Applicant and
the related entity and attach
supporting documentation:
Form 6: Documentation of Professional Liability Insurance
Offset Verifier Application for Accreditation
Version NY-1.0
Page 1 of 1
Form 6: Documentation of Professional Liability Insurance
Provide documentation in the fields below of professional liability insurance held by the
Applicant in an amount not less than one million ($1,000,000) U.S. dollars. Attach a copy of the
insurance certificate and other documentation as may be required to document the relationship
between a related entity that holds the insurance and the Applicant. The attachment(s) must
include a header that identifies it as an attachment to Form 6.
Name of Insurer:
Policy Number:
Amount of Coverage (US$):
Policy Expiry Date:
Deductibles (if any):
Exclusions (if any):
Name of the entity under
which the insurance is held:
If the insurance coverage is
held under the name of a
related entity, describe the
financial relationship
between the Applicant and
the related entity and attach
supporting documentation:
Form 6: Documentation of Professional Liability Insurance
Offset Verifier Application for Accreditation
Version NY-1.0
Page 1 of 1