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Notice of UMPhysicians Clinician Volunteer Activity [Multiple Activity Form] Please report all volunteer activities for which you provide clinical services and are looking to UMPhysicians malpractice insurance policy to provide coverage. The activity may occur once per year or more frequently. This information is needed by UMPhysicians to ensure insurance coverage. Physician name: CSU Telephone number: Name, address, telephone # of organization Dates & description of services you provide (or attach) Separate malpractice coverage? If yes, name of carrier, scope of coverage & policy limits (or attach) Physician Signature Date Division Director Approval Date Department Head Activity furthers the mission, vision and value of UMP and should be support by the CSU Activity does not further the mission, vision and value of UMP and will not be supported by the CSU Letter sent to physician notifying that activity has been denied Department Head Approval ___________________________________ Written contract? (If yes, please attach copy)