5 - MedPro Group



North Dakota Surplus Lines Warning Statement1. An insurer that is not licensed in this state is issuing the insurance policy that you have applied to purchase. These companies are called “nonadmitted” or “surplus lines” insurers. 2. The insurer is not subject to the financial solvency regulation and enforcement that applies to licensed insurers in this state. 3. These insurers generally do not participate in insurance guaranty funds created by state law. These guaranty funds will not pay your claims or protect your assets if the insurer becomes insolvent and is unable to make payments as promised. 4. Some states maintain lists of approved or eligible surplus lines insurers and surplus lines producers may use only insurers on the lists. Some states issue orders that particular surplus lines insurers cannot be used. 5. For additional information about the above matters and about the insurer, you should ask questions of your insurance producer or surplus lines producer. You may also contact your insurance department consumer help line._______________________ ______________________Applicant’s Signature DateIssuing Company: National Fire & Marine Insurance CompanyOmaha, NebraskaANCILLARY HEALTHCARE PROFESSIONAL LIABILITY APPLICATIONINSTRUCTIONSPlease answer all questions. If a question is not applicable, print, “n/a”. This application must be completed and signed by an authorized officer of the applicant.If additional space is needed, please use the Supplemental Information section at the end of the application and refer to the question or an additional form. I. GENERAL INFORMATIONA. FORMTEXT ????? Last Name FORMTEXT ????? First Name (Full) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? Middle NameSuffix Date of Birth MM/DD/YYYYB. Residence Address: FORMTEXT ????? FORMTEXT ????? Number & Street Apartment # FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? - FORMTEXT ???? City State Zip Code FORMTEXT ????? CountyII. PROFESSIONAL INFORMATIONNote: All percentages requested below for specialties are of the applicant’s total practice.Please enter complete name of specialty/sub-specialty and formal training program. Combined percentages for specialties must equal 100%.A. What is the applicant’s present specialty? FORMTEXT ????? FORMTEXT ??? % of total practice What is the applicant’s sub-specialty? FORMTEXT ????? FORMTEXT ??? % of total practiceB. Education / Training: FORMTEXT ????? FORMTEXT ????? Name of School Credentials (CRNA, OD, RN etc.) FORMTEXT ??? FORMTEXT ????? State Country Completed from: FORMTEXT ?? / FORMTEXT ???? To: FORMTEXT ?? / FORMTEXT ????MMYYYYMMYYYYC. To which Healthcare Professional Societies or Associations does the applicant belong? FORMTEXT ?????D. Is the applicant required to be licensed in the state(s) where the applicant practices? FORMCHECKBOX Yes FORMCHECKBOX No If yes, states in which the applicant holds a license to practice: Please check the appropriate box to indicate the status of the applicant’s license. (Exclude state abbreviation from license number.) Active Inactive Temporary Pending 1. State FORMTEXT ??? License # FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. State FORMTEXT ??? License # FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX E. Has the applicant completed a risk management education course within the last twelve (12) months? FORMCHECKBOX Yes FORMCHECKBOX NoF. Indicate the estimated average hours per week for which the applicant requires National Fire & Marine coverage. FORMTEXT ???? hrsG. Indicate the average hours per week devoted to treating or reviewing treatment of federal prison inmates. FORMTEXT ???? hrs FORMCHECKBOX None H. Indicate the average hours per week devoted to treating non-federal prison inmates. FORMTEXT ???? hrs FORMCHECKBOX NoneI. Will the applicant be performing activities which will be covered by another professional liability policy? FORMCHECKBOX Yes FORMCHECKBOX No If yes, is the applicant an: FORMCHECKBOX Employee FORMCHECKBOX Independent Contractor Practice Name: FORMTEXT ????? Location: FORMTEXT ????? Name of Insurer: FORMTEXT ????? J. Has the applicant ever been indicted for, charged with, or convicted of, any act committed in violation of any law or ordinance other than traffic offenses or had the applicant’s hospital privileges, DEA license, medical license or reimbursement privileges refused, denied, revoked, suspended, restricted, subject to a reprimand, placed on probation or voluntarily surrendered? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please indicate the date(s) and explain: Date FORMTEXT ?? / FORMTEXT ???? FORMTEXT ????? MM YYYYK. Has any professional liability insurance company ever declined, canceled, or non-renewed the applicant’s coverage? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please indicate the date(s) and explain: Date FORMTEXT ?? / FORMTEXT ???? FORMTEXT ????? MM YYYYL. Has the applicant ever been accused of sexual misconduct of any kind? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please indicate the date(s) and explain: Date FORMTEXT ?? / FORMTEXT ???? FORMTEXT ????? MM YYYYM. Has the applicant ever incurred or become aware of having a condition that impairs the applicant’s ability to practice the applicant’s medical specialty? (i.e. convulsive disorders, mental illness, multiple sclerosis, addiction of alcohol, narcotics or other controlled substances, etc.) FORMCHECKBOX Yes FORMCHECKBOX No If yes, state condition(s), date(s) and identify the applicant’s treating physician(s) in the space provided below. In the event of any such impairment, a statement from the applicant’s physician attesting to the applicant’s fitness to practice the applicant’s specialty must accompany this application. Type(s) of illness: FORMTEXT ????? FORMTEXT ????? Date(s) of treatment(s): From: FORMTEXT ?? / FORMTEXT ???? To: FORMTEXT ?? / FORMTEXT ???? FORMCHECKBOX Currently in treatment MM YYYY MM YYYY Name of treating physician(s): FORMTEXT ????? Address(es): FORMTEXT ????? FORMTEXT ?????N. Please check the box that best describes the applicant’s practice affiliation: FORMCHECKBOX Employed FORMCHECKBOX Self EmployedO. Does the applicant work for an entity or employer currently insured with National Fire & Marine Insurance Company? FORMCHECKBOX Yes FORMCHECKBOX No If yes, answer the following: Employment Status: FORMCHECKBOX Employee FORMCHECKBOX Shareholder/Partner FORMCHECKBOX Independent Contractor FORMCHECKBOX Other: FORMTEXT ????? Employer/Entity name: FORMTEXT ????? Please provide National Fire & Marine Insurance Company individual, corporation or partnership policy or group number: Policy #: FORMTEXT ????? Group #: FORMTEXT ????? Sub-group #: FORMTEXT ?????III. LOSS INFORMATION (Important! Please fully complete.)Please complete the Loss Information Supplement for each written request, incident, claim or suit (A, B or C) below that has NOT been covered by a National Fire & Marine policy.Report professional liability and malpractice related matters including, but not limited to, board complaints, etc.For Questions B and C below, report all matters that might reasonably lead to a claim or suit being brought against the applicant even if the applicant believes the claim or suit would be without merit.A. Is the applicant now, or has the applicant ever been, involved in a claim or suit arising out of the rendering or failure to render professional services? If yes, how many? FORMTEXT ??? None FORMCHECKBOX B. Is the applicant aware of any complication, incident or adverse outcome resulting in injury or death that might reasonably result in a claim or suit against the applicant? This includes, but is not limited to, the following: > Amputation > Death > Loss of major organ function > Loss of vision > Permanent neurological injury If yes, how many? FORMTEXT ??? None FORMCHECKBOX C. In the last 12 months, has the applicant or anyone from the applicant’s practice received a written request from an attorney for treatment records concerning any of the applicant’s current or former patients that might reasonably result in a claim or suit against the applicant? If yes, how many? FORMTEXT ??? None FORMCHECKBOX IV. COVERAGE INFORMATIONNotes:1. Claims-Made coverage is generally limited to liability for injuries for which claims are first made during the policy period, for services rendered between the retroactive date and expiration date of the policy. Please contact the applicant’s agent should the applicant have any questions pertaining to the differences between Claims-Made and Occurrence coverage or the additional expense associated with “extension contract” or “tail coverage”. 2. Requested limits and/or policy types may not be available in all states.A. Coverage Desired: FORMCHECKBOX Claims-Made coverage without Prior Acts coverage FORMCHECKBOX Occurrence coverage FORMCHECKBOX Claims-Made coverage with Prior Acts coverage FORMCHECKBOX Occurrence coverage with Prior Acts coverageB. Requested Coverage Period (12:01 am): From: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? To: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? Annual policy term will begin and end on the same month and day. MM DD YYYY MM DD YYYYC. The retroactive date shown on the applicant’s current Claims-Made policy is: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? (This date is required for Occurrence with Prior Acts or Claims-Made with Prior Acts.) MM DD YYYYD. Desired Limits: Per Occurrence/Per Claim Filed: FORMTEXT ????? Annual Aggregate: FORMTEXT ?????E. List all previous professional liability insurers within the past 10 years. 1. Current Insurer: FORMTEXT ????? FORMCHECKBOX Occurrence FORMCHECKBOX Claims-Made From: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? To: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ????MMDDYYYYMMDDYYYY 2. Previous Insurer: FORMTEXT ????? FORMCHECKBOX Occurrence FORMCHECKBOX Claims-Made From: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? To: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ????MMDDYYYYMMDDYYYY 3. Previous Insurer: FORMTEXT ????? FORMCHECKBOX Occurrence FORMCHECKBOX Claims-Made From: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? To: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? MMDDYYYYMMDDYYYYF. If “Occurrence” or “Claims-Made coverage without Prior Acts coverage” was selected as the desired coverage and the most recent prior coverage was issued on a Claims-Made basis, please complete one of the following: FORMCHECKBOX An extended reporting endorsement (tail coverage) has been or will be purchased. FORMCHECKBOX An extended reporting endorsement has not and will not be purchased. I will not purchase tail coverage (reporting endorsement) from my current insurer where I am insured under a Claims-Made policy. I realize that my failure to purchase such coverage from my current insurer will result in an uninsured exposure for any claims which may arise as result of professional services rendered while insured by my current insurer’s policy. I understand that the policy FORMTEXT ????? for which I am applying for with National Fire & Marine Insurance Company, if offered, will not provide Prior Acts coverage. Initial Here V. IMPORTANT NOTICEThis insurance may contain claims-made and reported coverage. Certain coverages of this insurance may be limited to liability for injuries for which claims are first made during the policy period arising out of incidents or acts that first occurred on or after the applicable retroactive date which are reported to the Company during the policy period or any applicable extended reporting period. Please read and review the policy carefully.VI. FRAUD NOTICEMANDATORY: ALL APPLICANTS MUST READ AND INITIAL THE FOLLOWING:ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DECEIVE, OR DEFRAUD ANY INSURANCE COMPANY OR OTHERPERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR FAILS TO PROVIDE COMPLETE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND MAY BE PROSECUTED UNDER STATE LAW AND FORMTEXT ?????MAY BE GUILTY OF A FELONY AND SUBJECT TO CRIMINAL AND CIVIL PENALTIES, FINES, DENIAL OF INSURANCE OR Initial HereCONFINEMENT IN PRISON. VII. STATE SPECIFIC NOTICESIf Delaware: National Fire & Marine Insurance Company recognizes the rights afforded to individuals under The Delaware Civil Union & Equality Act of 2011 and Delaware Bulletin No. 46 including the following: Parties to a civil union shall have all of the same rights, protections and benefits, and shall be subject to the same responsibilities, obligations and duties, under Delaware law as are granted to, enjoyed by, or imposed upon married spouses. A party to a civil union shall be included in any definition or use of the terms "dependent", "family", "husband and wife", "immediate family", "next of kin", "spouse", "stepparent", "tenants by the entirety", and other terms, whether or not gender-specific, that denote a spousal relationship or a person in a spousal relationship, as those terms are used throughout Delaware law. For all purposes of Delaware laws that refer to marriage or marital status, other than Chapter 1 of Title 13 of the Delaware Code, parties to a civil union will be included in such reference. The Act automatically recognizes as civil unions for all purposes of Delaware law legal unions between two persons of the same sex, such as civil unions, marriages and domestic partnerships that are validly formed in jurisdictions other than Delaware and are substantially similar to Delaware civil unions.If Illinois: National Fire & Marine Insurance Company recognizes the rights afforded to individuals under Illinois Bulletin 2011-06 And The Religious Freedom Protection and Civil Union Act which states: “The parties to a civil union are entitled to the same legal obligations, responsibilities, protections and benefits that are afforded or recognized by the laws of Illinois to spouses. The law further provides that a party to a civil union shall be included in any definition or use of the terms “spouse,” “family,” “immediate family,” “dependent,” “next of kin,” and other terms descriptive of spousal relationships as those terms are used throughout Illinois law. This includes the terms “marriage” or “married” or variations thereon. If policies of insurance provide coverage for children, the children of civil unions must also be provided coverage. The Act also requires recognition of civil unions or same sex civil unions or marriages legally entered into in other jurisdictions.”If Rhode Island: THIS INSURANCE CONTRACT HAS BEEN PLACED WITH AN INSURER NOT LICENSED TO DO BUSINESS IN THE STATE OF RHODE ISLAND BUT APPROVED AS A SURPLUS LINES INSURER. THE INSURER IS NOT A MEMBER OF THE RHODE ISLAND INSURERS INSOLVENCY FUND. SHOULD THE INSURER BECOME INSOLVENT, THE PROTECTION AND BENEFITS OF THE RHODE ISLAND INSURERS INSOLVENCY FUND ARE NOT AVAILABLE.VIII. PLEASE READ AND SIGNBy my signature, I hereby represent that the Named Insured has extended to me full authority to execute this application on his, her or the facility/entity’s behalf and that I am authorized to represent and sign on behalf of the Named Insured, or any person, or facility/entity requesting coverage in this insurance application. I also represent that I have reviewed the responses contained in this application and represent them to be complete and accurate to the best of my knowledge. In addition, I understand and agree that such representations are binding upon the Named Insured and all persons and facility(ies)/entity(ies) even though I am executing this application on their behalf. I further acknowledge that any and all responses to questions, statements and explanations made in this application, or in any and all documents, supplemental pages or other attachments (hereinafter "Attachments") are true and that neither I, nor any applicant, have knowingly suppressed or misstated any material facts and I, and any applicant, agree that this application, and any Attachments, shall be the basis of the contract with the Company. ?I AGREE THAT IF I FAIL TO COMPLY WITH THESE TERMS THE APPLICANT WILL HAVE NO COVERAGE FOR ANY CLAIM UNDER ANY POLICY OF INSURANCE FOR WHICH WE ARE APPLYING.?Completion of this form does not bind coverage or obligate the Company to offer coverage. The Company’s receipt of the applicant’s acceptance of the Company’s quotation is required before the coverage may be bound and the policy issued. I further understand and agree that I, or any applicant, have no right to demand or expect coverage until the Company has: (1) received the completed application(s); (2) offered a premium quote; and (3) received, as a precondition to coverage, the total premium due or, if the Company has agreed to finance the premium, the first installment due. ?I agree to cooperate with the Company in implementing an ongoing program of loss control and will allow the Company to review and monitor such programs that the applicant undertakes in managing its professional and general liability insurance exposures.?I understand and agree that a credit report, a credit score, an annual report, and an actuarial study may be obtained, reviewed or used in connection with the submission of this application. ?I understand and agree that the Company may wish to contact persons, hospitals, employers, insurance agents, prior insurance carriers or other entities to verify and/or ascertain information regarding credentials and background both prior to and if bound after the issuance of a contract of insurance, therefore. ?The applicant hereby authorizes and directs any person or organization whatsoever to release and furnish to the Company, and its agents or representatives, any and all information requested which may relate to insurability under the policy. The applicant furthermore authorizes the release of all such information by the Company as required by law to any governmental agency or professional society or association. The applicant furthermore releases and agrees to hold harmless the Company, and all of its agents and representatives, any prior insurer, governmental agency, or professional society or association from any liability arising out of the release or review of any and all information released or furnished pursuant to this authorization and application for insurance, notwithstanding the fact that there may be errors, omissions, or mistakes contained in such released information.By signing this application on behalf of the applicant (which may include a professional corporation, a professional association, a limited liability company, a general business corporation, a partnership, a joint venture, or a governmental entity), I represent that I am an Officer, Shareholder, Partner, or other Authorized Representative of the group or entity applying for coverage.?This application must be signed by the President, Chief Executive Officer, or other Officer, Shareholder, or Partner of a PC or PA, or the equivalent Authorized Representative.? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Signature of Officer or Authorized Representative Title DateIX. SUPPLEMENTAL INFORMATION-The following must complete this supplemental: “Healthcare Professionals Directly Assisting in Surgery, Nurse Practitioners, Physician’s Assistants, and Podiatrists”.A. Please check any of the following functions performed as part of the applicant’s professional activities. FORMCHECKBOX Limited “Scrub Nurse” functions such as holding retractors, suction, tying sutures, handing and counting of instruments. FORMCHECKBOX Casting and Splinting. FORMCHECKBOX Directly assisting as a non-physician first assistant in surgical procedures.B. If the applicant is a Podiatrist, does the applicant perform surgery? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please indication the type of surgeries the applicant performs. FORMTEXT ?????C. Does the applicant independently prescribe/order drugs without physician review? FORMCHECKBOX Yes FORMCHECKBOX NoX. SUPPLEMENTAL INFORMATION FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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