Chiropractic Associates  
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Apply to Be an SCC Associate 
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Please complete the information below. We do not reveal you information to third parties, so this information is strictly confidential.

You may also print this form and mail or fax it to us at the address at the bottom of the page.
Name of Participating Chiropractor
Name of D.C.Firm (if different)
Street or Mailing Address
City/State/ZIP
Telephone
Email Address
Website URL
Licensed in State(s)
Years of Chiropractic Personal Injury Practice
Rough Estimate Number of Plaintiff’s Depositions, Arbitrations, or Trials Past Five Years
Name, Address, and Phone Number of a Plaintiff’s Trial Attorney With Whom You Have Worked in Past Five Years
Any Professional Complaints Filed Against You?  If so, Please Explain.
ACA member? YesNo
Other Noteworthy Professional or Civic Associations
Carry Malpractice Insurance? YesNo
Second Language Spoken in Office?
Further Explanations or Comments

If you'd prefer, you may print the application and fax or mail it to us
Fax 360.871.7506
Mail SettlementCentral.Com
1426 Harvard Avenue #466
Seattle, WA 98122-3813