Specialty Custom Insurance Services, LLC
Capitol Specialty Insurance CorporationA Stock CompanyP. O. Box 5900Madison, WI 53705-Medical Spa Supplemental ApplicationI. APPLICANT INFORMATION1.1Applicant Name: FORMTEXT ?????1.2Primary Business Address: FORMTEXT ????? FORMTEXT ?????1.3Applicant ContactName: FORMTEXT ?????Email Address: FORMTEXT ?????1.4Website(s): FORMTEXT ?????II. BUSINESS INFORMATION2.1Does the Applicant provide any other services, including other medical services, besides the medical spa services listed in Question 3.4 below? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please provide details (use a separate sheet if needed): FORMTEXT ?????2.2Does the Applicant use any medications or products or perform any procedures which are not FDA approved? FORMCHECKBOX Yes FORMCHECKBOX No2.3Does the Applicant use any medications or products in a manner other than as specified in the FDA’s approved packaging label? FORMCHECKBOX Yes FORMCHECKBOX No2.4Does the Applicant have a formalized employee verification program including background checks performed prior to hire? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, are any negative findings discovered in this process investigated and duly considered in the hiring process? FORMCHECKBOX Yes FORMCHECKBOX No2.5Who is the Applicant’s Medical Director? FORMTEXT ?????What is their medical specialty? FORMTEXT ?????What type of coverage is requested for the Medical Director? FORMCHECKBOX Coverage for Administrative Duties only FORMCHECKBOX Coverage for both Administrative Duties and Direct Patient CareIII. PROFESSIONAL SERVICES AND STAFFINGPlease conduct due diligence prior to completing the information below to ensure that it is accurate. The following information is critical to make an accurate assessment of the Applicant. 3.1Indicate the number of the Applicant’s staff in each category below, and whether they carry their own professional liability insurance:EmployedContractorStaff TypeFull TimePart TimeFull TimePart TimeCarry Own Professional Liability Insurance?Aesthetician FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoLaser Technician FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoLPN / RN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoMedical Assistant FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoNurse Practitioner FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoPhysician Assistant FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoPhysician FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoOther, please describe: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No3.2Are all of the above individuals licensed and/or certified in accordance with applicable state and federal regulations? FORMCHECKBOX Yes FORMCHECKBOX No3.3Has the Applicant or any of the above-referenced staff:ever been under the investigation of a regulatory agency for professional misconduct? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT ?????ever been treated for alcoholism or drug addiction? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT ?????ever had any state professional license to prescribe narcotics suspended, revoked, refused, restricted or voluntarily surrendered? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT ?????3.4Do all of Applicant’s medical professionals take pictures of subjects both before and after cosmetic procedures? FORMCHECKBOX Yes FORMCHECKBOX NoIf no, please explain: FORMTEXT ?????3.5Do all patients sign consent forms, in advance, which are specific to the services provided or procedures being performed? FORMCHECKBOX Yes FORMCHECKBOX NoIf no, please explain: FORMTEXT ?????3.6If services or procedures are to be performed on a minor, is a signed parental consent form obtained, in advance, which is specific to the services provided or procedures being performed? 3.7Do medical professionals ever perform any services or procedures offsite (away from the business premises listed in Question 1.2 above)? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT ?????3.8Please provide the following information for procedures the Applicant is performing this calendar year. Indicate the number of times each procedure has been performed this year to date, and the estimated number of times each procedure will be performed for the entire year.Procedure(s)Current NumberProjected Number for Year Professional Performing ProcedureAcne Blue Light FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Acupuncture FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????BHRT FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Body Wraps FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Botox FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Chelation Therapy FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Chemical Peels: FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????30% acidity or less: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Over 30% acidity: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Colonics FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Cool Sculpting FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Cryotherapy FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Day Spa services (waxing, hair, nails, reflexology, aromatherapy) FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Dermal Fillers FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Ear Candling FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Electrolysis FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Facials – Basic / Special FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Fat Injections FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Hair Transplant FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????HCG (for weight loss only) FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Hormone Therapy (NO BHRT), explain type: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Invasive Lipolysis FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????IPL FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Laser Hair Removal FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Laser Skin Treatment FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Laser Tattoo Removal FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Laser Vein up to 1.5 mm FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Latisse FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????LED Hair Stimulation FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Lipo-Dissolve FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Lipo Injections FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Lipolysis FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Liposuction FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Laser Assisted FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Tumescent FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Low T FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Mesotherapy FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Microblading FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Microdermabrasion FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Microneedling FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Non-surgical cellulite treatment (velashape, thermage & endermologie) FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????P - Shot FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Pain Management (if yes, please complete Pain Management Supplement) FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Permanent Makeup FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Photo Therapy FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Plastic / Cosmetic Surgery, describe surgical procedures: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????PRP Injections FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????O - Shot FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Sclerotherapy FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Skin Tag Removal FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Stem Cell-Based – Adipose (Fat) FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Stem Cell-Based – Bone Marrow FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Stem Cell-Based – Engineered FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Stem Cell-Based – Umbilical Cord / Placenta FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Teeth Whitening FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Thread Face Lift FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Vaginal Rejuvenation FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Vitamin Injections FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Weight Loss Counseling FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????Other, please describe: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX LPN FORMCHECKBOX NP FORMCHECKBOX Nurse FORMCHECKBOX PA FORMCHECKBOX Physician FORMCHECKBOX Other, please list: FORMTEXT ?????3.9Are there any procedure listed above and/or not listed above that the Applicant has performed in the past, but is no longer performing now? If yes: FORMCHECKBOX Yes FORMCHECKBOX NoWhat is the procedure? FORMTEXT ?????When was the procedure first performed? FORMTEXT ?????When was the procedure last performed? FORMTEXT ?????How many times had the procedure been performed in the past? FORMTEXT ?????If more than one procedure should be listed above, please indicate this information in a separate attachment.3.10Does the Applicant make any promises or guarantees relating to any treatment, procedure or therapy? FORMCHECKBOX Yes FORMCHECKBOX No3.11Specifically, in the Applicant’s marketing, advertising, website or informed consent forms, does the Applicant make any promises or guarantees relating to any treatment, procedure or therapy involving the use of stem cells, including but not limited to its safety or effectiveness, its status as approved or not approved by the U.S. Food and Drug Agency (FDA), or whether or not it has any proven medically beneficial use? FORMCHECKBOX Yes FORMCHECKBOX No3.12Does the Applicant disclose and sufficiently warn patients about the potential dangers or side-effects of any stem-cell treatment, procedure or therapy? FORMCHECKBOX Yes FORMCHECKBOX NoIV. CLAIMS AND INCIDENTS Please respond to the following questions to the best of your knowledge and belief, after conducting due diligence and inquiry with any individuals who may have knowledge or information about the matters described below.The term “Applicant” as used below, means any proposed insured, including any individual or entity for whom coverage is sought.4.1During the past five (5) years, has the Applicant received notice of any claim, suit, legal proceeding or regulatory/licensure action against any proposed insured relating to professional services, or for which coverage may be sought under the Policy applied for? FORMCHECKBOX Yes FORMCHECKBOX No4.2Within the past five (5) years, has the Applicant given written notice to its any current or prior professional or general liability insurance carrier of any claim, suit, legal proceeding or regulatory/licensure action, or of any facts, circumstances or situations which might give rise to a claim, suit, legal proceeding or regulatory/licensure action against any proposed insured relating to professional services? FORMCHECKBOX Yes FORMCHECKBOX No4.3Is the Applicant or any proposed insured aware of any facts, circumstances, situations, transactions, events, acts, errors or omissions which could reasonably be expected to give rise to a claim, suit, legal proceeding or regulatory/licensure action against any proposed insured relating to professional services, or for which coverage may be sought under the Policy applied for? FORMCHECKBOX Yes FORMCHECKBOX No4.4In the past five (5) years, has any proposed insured entity, or professional employee of Applicant, or other proposed insured, had their professional licenses or certifications suspended or revoked, or been investigated for professional misconduct? FORMCHECKBOX Yes FORMCHECKBOX No4.5During the past three (3) years, has any professional or general liability insurance carrier cancelled or nonrenewed Applicant’s insurance coverage, declined any application for coverage or refused to issue any policy to Applicant? FORMCHECKBOX Yes FORMCHECKBOX NoThe policy for which the Applicant is applying, if issued, will not insure: any claim, suit, proceeding or regulatory/licensure action disclosed, or which should have been disclosed, in response to the above; or any claim, suit, proceeding or other regulatory/licensure action that arises from any fact, circumstance, situation, transaction, event, act, error or omission disclosed, or which should have been disclosed, in response to the above.IF YOU REPLY “YES” TO ANY OF THE QUESTIONS IN IV. CLAIMS AND INCIDENTS ABOVE, PLEASE PROVIDE DETAILS IN A SEPARATE ATTACHEMENT AND ATTACH CURRENT LOSS RUNS.V. FRAUD WARNINGSAny person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects that person to criminal and civil penalties.(Not applicable in AL, AR, CO, DC, FL, KY, KS, LA, ME, MD, NJ, NM, NY, OH, OK, OR, PA, RI, TN, VA, VT, WA and WV).APPLICABLE IN AL, AR, DC, LA, MD, NM, RI AND WVAny person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD only.APPLICABLE IN COIt is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.APPLICABLE IN FL AND OKAny person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL only.APPLICABLE IN KSAny person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.APPLICABLE IN KY, NY, OH AND PAAny person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY only.APPLICABLE IN ME, TN, VA AND WAIt is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME only.APPLICABLE IN NJAny person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.APPLICABLE IN ORAny person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.APPLICABLE IN VTAny person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.VI. REPRESENTATIONSThis Application must be signed by an authorized partner, officer or other principal of Applicant shown in Question 1.1 of this Application.By signing this Application, the undersigned represents, on behalf of the Applicant and all proposed insureds, the following:After conducting due diligence, the statements in the Application and Supplemental Application furnished to the Company are accurate and complete;Those statements furnished to the Company are representations Applicant makes on behalf of all proposed Insureds;Those representations are a material inducement to the Company to provide a premium proposal;If a policy is issued, the Company will have issued this Policy in reliance upon those representations;If there is any material change in the Applicant’s condition or in the Applicant’s activities, services, or answers provided in this Application that occurs or is discovered between the date this Application is signed and the Effective Date of any policy, if issued, Applicant will immediately report such material change to the Company in writing; andThe Company reserves the right, upon receipt of such notice, to change or rescind any proposal previously offered by the Company.As used above, the term “Company” refers to Capitol Specialty Insurance Corporation.NOTHING IN THIS APPLICATION SHOULD BE INTERPRETED TO MEAN THAT COVERAGE WILL BE OFFERED OR THAT ANY ITEMS REFERENCED IN QUESTIONS OR ANSWERS TO QUESTIONS WILL BE COVERED EVEN IF COVERAGE IS OFFERED AND BOUND. SOME RESPONSES MAY REQUIRE MORE SPACE THAN THAT PROVIDED IN THE APPLICATION ITSELF. PLEASE PROVIDE THOSE RESPONSES ON A SEPARATE PAGE AND ATTACH IT TO THIS APPLICATION. FORMTEXT ?????Signature of authorized representative of ApplicantTitle FORMTEXT ????? FORMTEXT ?????Type / Print name of authorized representativeDate FORMTEXT ?????E-mail address of authorized representative ................
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