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Prof Laibility - medicos - SSS

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					                                                                                      SEGUROS TRIPLE-S, INC.

PROFESSIONAL LIABILITY INSURANCE (CLAIMS MADE)
FOR PHYSICIAN, SURGEON, DENTIST OR ORAL SURGEON APPLICATION

1. Name of Insured __________________________________________________________________________________________
                                 Father's last name               Mother's last name            Name            Initial
2. Place of Birth _________________________ Date of Birth _________________ Age ______Citizenship _____________________
3. Home Address ______________________________________________________________ Home Telephone _______________
4. Office Address ____________________________________________________________________________________________
    Mailing Address ___________________________________________________________________________________________
   Office Telephone ___________________________________ Radio Call Beeper Unit ____________________________________
5. Coverage period interested: From_______________________________ To __________________________________________
6. Limits of Liability: Each Medical Incident _______________________________ Annual Aggregate _________________________
7. Number of Years at current office location ______________________________________________ Previous Locations Of Practice
  (Indicate places and dates) ___________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
8. Medical School ___________________________________________________ Degree ___________ Year ____________
   Address ________________________________________________________________________________________________
   Served Internship _____________________ Year ___________ served residency at ________ Year ____________
   Address __________________________________________________ Address ___________________________________
If foreign medical school graduate, Are you certified by the Educational Council for medical school graduates? (   ) Yes (   ) No (If
"Yes", Indicate year __________________________
Name Country, State National Medical Associations or Societies of which you are A member in good standing:
1. __________________________________________ 3. ____________________________________________
2. __________________________________________ 4. ____________________________________________
9. What is (are) your present specialty (ies) as designed by the American Medical Association?
   _________________________________________________________________________________________________________
  are you registered and licensed to practice your profession in the commonwealth of Puerto Rico? If "Yes" give license number
  ______________________________________________ date issued _________________________________________________
  What is (are) your Sub-Specialty (ies), (if any) : ___________________________________________________________________
  Name specialty board certifications which your hold : (1) _________________________________ year ______________________
  (2) _____________________________ year ___________________ (3) _____________________________ year _____________
10. Indicate which of the following procedures you perform, if any, and what percentage
    Of Your Total Work Is Involved In Every Procedure You Perform.
                                                                                                          PERCENTAGE
              a.   Acupunture -other than acupunture anesthesia
              b.   Angiography
              c.   Arteriograph
              d.   Catherization-arterial, cardiac or diagnostic- other than
              e.   Discograms
              f.   Endoscopy- Retrograde Cholangiopancreatography
              g.   Laporoscopy (peritenoscopy)
              h.   Lasers- used in therapy
              i.   Lymphaniography
              j.   Myleography
              k.   Needle Biopsy-including lung, liver, kidney and prostate
              l.   Phlebography
              m.   Pneumatic or mechanical esophageal dilatation
              n.   Pneumoencephalography
              o.   Radiation therapy - The treatment of disease with any type of radiation
              p.   Radiopaque dye injections into blood vessels, lynmphatic sinus tracts and fistulae
              q.   Shock therapy - The treatment of certain psycotic disroders by the injection of
                   drugs, or by electrical shocks, both methods inducing coma, with or without
                   convulsions.

If You Do Not Perform Any Of Said Procedures, Please Indicate "None" In The Following Space
___________________________________________________________________________________________________________

SSS 477 (03/04)                                                                                 Page 1 of 5
11. Indicate which of the following procedures you perform, if any, and what percentage of your total work is involved in every
    Procedure You Perform.
                                                                                                       PERCENTAGE
              a.   Minor "surgery other than incision of boils and superficial fascia
              b.   Assisting in major *surgical procedures on your own patients
              c.   Major *surgery
              d.   Assisting in major * surgical procedures on other than your own patients
              e.   Normal obstetrical procedures not considered to be major *surgery
              f.   Obstetrical procedures which are considered to be major *surgery
              g.   Plastic surgery - reconstructive
              h.   Plastic surgery - cosmetic
              i.   Weight control (other than by diet)
              j.   Administer general anesthesia

*    MAJOR SURGERY- Includes operations in our upon any body cavity, including but not limited to be cranium, thorax, abdomen or
     pelvis; any other operation which, because of the condition of the patient or the length or circumstances of the operation, presents
     a distintic hazard to life. It also includes: removal of tumors, bone fractures, amputations, the removal of any gland or organ and
     plastic surgery. Tonsillectomies, adenoidectomies and Cesarean Sections are considered to be a major surgical procedures.
     Assisting in major surgery. Assisting in major surgery on your patients.

If You Do Not Perform Any of Said Procedures, Please Indicate "None"In the Following Space
___________________________________________________________________________________________________________

12. (To be completed by ODONTOLOGISTS. Are you engaged oral surgery or operative dentistry on patients rendered unconscious
through the administering of any analgesia or anesthesia/ in your office?        ( ) Yes ( ) No
If "Yes", please answer following questions. Also indicate what percentage of your total work is involved):


If the analgesia -anesthesia rendering patients unconscious is administered in your office by you or by any other person(s) other than
yourself, indicate type(s) used:

___________________________________________________________________________________________________________
                                   (topical, local infiltration, endovenous, inhalation)

If the analgesia-anesthesia rendering patients unconscious is administrated in your office by any other person(s), other than yourself,
please indicate by whom:

___________________________________________________________________________________________________________
                                     (anesthesiologist, anesthetist, nurse, other)

Indicate if the person(s), other than yourself, administering analgesia-anesthesia redressing patient unconscious while at your office
do(es) so pursuant to a:

( ) Verbal agreement
     Indicate terms: __________________________________________________________________________________________

( ) Written agreement or contract for services, enclose copy of the same.

Indicate who assumes payment for said services:

( ) Patient and/or his insurance carrier is billed directly for the administration of analgesia-anesthesia rendering patient unconscious
separately of the dental fees charged.

( ) Applicant odontologist includes and comprises said charges within his dental fees.

Have you received training in cardio pulmonary resuscitative measures. ( ) Yes ( ) No
If "Yes" indicate dare of "C.P.R." training, where taken and sponsored by whom:

___________________________________________________________________________________________________________

Enclose copy(ies) of the certificate of attendance to the "C.P.R." training course(s) you have taken.


13. Name all Hospitals at which you have had or have staff membership or privileges and give nature of privileges at each and the
dates during which those have been enjoyed:
___________________________________________________________________________________________________________

14. In case of any "Yes" answer to any to the following questions, please explain details in the space provided below: indicating nature
of action date, country or state action took place, reasons for the same.

a. Has your license to practice your profession ever been refused, suspended, revoked or voluntarily surrendered in Puerto Rico or
elsewhere. If "Yes" offer details for said action.                                       ( ) Yes ( ) No

b. Has your membership in any professional society or association ever been refused, suspended, revoked or voluntary surrendered in
Puerto Rico or elsewhere:
If "Yes" offer details for said action.

c. Has any Hospital in Puerto Rico or elsewhere ever restricted, suspended or revoked your privileges or revoked probation? If "Yes"
offer details:                                                                           ( ) Yes ( ) No
SSS 477 (03/04)                                                                                 Page 2 of 5
d. Have you ever had Board Certification refused or revoked: If "Yes" offer details`           ( ) Yes ( ) No

e. Do you plan to take additional residences or change specialty within the next two years?             ( ) Yes ( ) No
f. Do you work (full or part-time) in an emergency room or intensive care unit?                         ( ) Yes ( ) No


g. Do you perform or engage in any surgical procedure in your professional office or other similar non-hospital facility during the course
of which analgesia-anesthesia rendering patient unconscious is administered either by yourself of others?
                                                              ( ) Yes ( ) No

h. Do you maintain recovery beds for overnight patients in your office?                                 ( ) Yes ( ) No

i. Are you employed or have your been in any capacity by any person or organization on salary or commission? If "yes", name of group,
capacity with employed date.                                                             ( ) Yes ( ) No

j. Are or have your been you active in U.S. Military Service? If "Yes" indicate position, where         ( ) Yes ( ) No
  and dates.

k. Are you have you been employed by the federal government (not active in U.S. Military Service)?
   If "Yes"indicate in what capacity, where and dates:                                             ( ) Yes ( ) No

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

15. Are you a partner, stockholder or member in a medical, association, corporation or joint venture?
                                                                                                    ( ) Yes ( ) No
16. If answer to above question in "Yes", please give following details:

a. Name of partnership ( ) Association ( ) Corporation ( ) Joint Venture ( ) ___________________________________________

b. List all member doctors and specialty(ies):

           Name _________________________________________ Specialty ____________________________________________

           Name _________________________________________ Specialty ____________________________________________

           Name _________________________________________ Specialty ____________________________________________

17. Do you (or does your partnership/corporation/ joint venture) employ any of the following:

           a. Licensed Physicians or Surgeons? ( ) Yes ( ) No If "Yes", please give the following information:

           Name ________________________________________ Specialty _____________________________________________

           Performs X-Ray Therapy ( ) or Shock Therapy ( )

           Name ________________________________________ Specialty ______________________________________________

           Performs X-Ray Therapy ( ) or Shock Therapy ( )

           Name ________________________________________ Specialty ______________________________________________

           Performs X-Ray Therapy ( ) or Shock Therapy ( )

           b. Licensed Physicians or Surgeons Assistants? ( ) Yes ( ) No. If "Yes", How many? ______________________________

           Note: A Physician's or Surgeon's Assistant is one who has completed an approved course of study leading to university
           certification and who perform his duties under the direct supervision of a licensed physician or surgeon, assisting in the clinical
           and/or research endeavors of the physician or surgeon.
           c. Licensed Dentist? ( ) Yes ( ) No. If "Yes", please indicate below name of each and whether a specialized in oral surgery:

           Name _____________________________________________ Oral Surgery ( ) Yes ( ) No

           Name _____________________________________________ Oral Surgery ( ) Yes ( ) No

           d. Licensed Technicians: Radium ( ) Yes ( ) No. Laboratory ( ) Yes ( ) N0

              Pathological ( ) Yes ( ) No X-Ray ( ) Yes ( ) No

              Or Shock Therapy ( ) Yes ( ) No. If "Yes", please indicate how many of each kind: ______________________________


           ____________________________________________________________________________________________________

           18. Are you affiliated in any supervisory or administrative capacity or do you have an ownership interest in:

           a. Any hospital or clinic with bed and accommodations?                                       ( ) Yes ( ) No

           b. Any clinic, blood bank, laboratory or similar facility?                                   ( ) Yes ( ) No

           i. Full name and location of the facility as well as the specific name of the Department of Ancillary service with which you are
           affiliated or official committee on which you serve: ___________________________________________________________
           ____________________________________________________________________________________________________
SSS 477 (03/04)                                                                                   Page 3 of 5
           ii. Designate the exact capacity in which you serve(e.g. owner or in part, executive officer, administrator, department or
           ancillary service or supervisor, physician with teaching responsabilities, etc.): ______________________________________

           iii. Indicate the number and specific profession classification of assistants (physician or non-physician) employed
           by or rendering service for the above named facility who work under your supervision, direction or control or for
           whose acts you have assumed legal responsibility either by reason of your official appointment or under terms of
           any contract or agreement: ______________________________________________________________________________
           ____________________________________________________________________________________________________

           19. If you answer "Yes", to any of the following question PLEASE GIVE DETAILS BELOW:

         a. Do you engage in any colleague group activities including but not limited to service as a member of a normal
            accreditation of similar professional board or committees, of a hospital or professional, tissue committee,
            hospital credential committee or professional society peer committee?                        ( ) Yes ( ) No

       * b. Have you ever had your license to prescribe or dispense narcotics refused, suspended or revoked?
             If, "Yes", indicate or state, date and reason for said action.                        ( ) Yes ( ) No

        * c. Have you ever been treated and /or hospitalized for alcoholism, narcotics, addiction or mental illness?
             If "Yes", indicate by whom, where and date.                                     ( ) Yes ( ) No

         * d. Have you now, or ever had, any chronic illness or physical defect?                          ( ) Yes ( ) No
              If "Yes", indicate nature.

          *e. Have you ever been convicted of a crime?                                                    ( ) Yes ( ) No
              If "Yes", indicate nature, place, date court case number and conviction

         *20. Has any claim or suit for any alleged malpractice ever been brought against you?            ( ) Yes ( ) No

              If "Yes" enclose copy of notice of intent to file claim, notice of extrajudicial claim and/or complaint for each and
             every case and a status report regarding each prepared by the insurance carrier providing coverage for said
             claim or by your defense counsel in said case indicating:
                  -   loss indemnity paid by you or your behalf either per settlement or per judgement
                  -   name of claimant, case number and court
                  -   date of loss
                  -   nature of alleged malpractice
                  -   if case not resolved, stage of legal proceedings

         *21. Are you aware of any acts, errors, omissions, or circumstances which may result in a malpractice or suit which
              has not yet been brought against you?

              If answer is "Yes". submit details: ______________________________________________________________________
             __________________________________________________________________________________________________
             __________________________________________________________________________________________________
             __________________________________________________________________________________________________
                  _________________________________________________________________________________________________
        *22. Have you submitted to your last claims made malpractice insurer a list of any acts, errors, omissions or
             circumstances which may result in possible future malpractice claims or suits brought against you.
                                                                                                               ( ) Yes ( ) No
             If answer is "Yes":

            a.      Provide a copy of said list.
            b.      Indicate the date on which said list was submitted to your last claims made malpractice insurer:

                       Mo.                Day              Year               Name of Insurer and Address

           If answer is "No", please explain, _________________________________________________________________________
           ____________________________________________________________________________________________________
          ____________________________________________________________________________________________________
          ____________________________________________________________________________________________________
   *23. Have you ever had Professional Liability Insurance declined, cancelled, issued on special terms or renewal
        refused? If "Yes" indicate name of insurer, policy if applicable, ate and reason for said reaction.  ( ) Yes ( ) No

    *24. Please give name of your last insurer and policy number: ______________________________________________________
         Type of coverage: ( ) Occurrence, ( ) Claims Made

    *25. If claims made type of coverage please give number of years and/or months insured under the claims made
         program: Number of Years: ________________________________ Number of Months: _____________________________

    *26. If claims made type of coverage, has it been continuosly if force? _______________ Yes ______________ No

          If "No", please explain, __________________________________________________________________________________
          ____________________________________________________________________________________________________
          ____________________________________________________________________________________________________

    * Failure to render complete and/or to submit requested information and/or documents to each of these questions will
      cause delay and/or impair Insurer in considering the convenience or desirability of selecting applicant for the
SSS 477 (03/04)                                                                                    Page 4 of 5
     Insurance coverage requested.




    Completion of this application creates no obligation upon the applicant to accept Insurance or upon SEGUROS TRIPLE-S, INC. to
    offer Insurance, however, In the event that such Insurance is accepted by the applicant or that it is issued by SEGUROS TRIPLE-S,
    INC. this applicant will form the basis for that acceptance and Issuance.

    Note: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
    insurance containing any false information or conceals, for the purpose of misleading, information concerning any fact material there
    to commits a fraudulent act and is in violation of section 27.190of the Insurance Code of Puerto Rico.

   I authorization release and exchange of information involving but no limited to claim matters between any hospital, my
   professional society or association, previous insurance carrier and the company in which I am applying for insurance.

   CERTIFICATION:

   I certify that the foregoing representations are true, complete and correct to the best of my knowledge and belief in all
   respects and request the company to issue the insurance and renewal in reliance thereon.


NOTA IMPORTANTE; “CUALQUIER PERSONA QUE A SABIENDAS Y QUE CON LA INTENCION DE DEFRAUDAR PRESENTE
INFORMACION FALSA EN UNA SOLICITUD DE SEGURO O, QUE PRESENTARE, AYUDARE O HICIERE PRESENTAR UNA
RECLAMACION FRAUDULENTA PARA EL PAGO DE UNA PÉRDIDA U OTRO BENEFICIO, O PRESENTARE MAS DE UNA
RECLAMACION POR UN MISMO DAÑO O PERDIDA, INCURRIRA EN DELITO GRAVE Y CONVICTO QUE FUERE, SERA
SANCIONADO, POR CADA VIOLACION CON PENA DE MULTA NO MENOR DE CINCO MIL (5,000) DOLARES, NI MAYOR DE
DIEZ MIL (10,000) DOLARES O PENA DE RECLUSIÓN POR UN TÉRMINO FIJO DE TRES(3) AÑOS, O AMBAS PENAS. DE
MEDIAR CIRCUNSTANCIAS AGRAVANTES, LA PENA FIJA ESTABLECIDA PODRÁ SER AUMENTADA HASTA UN MÁXIMO
DE CINCO (5) AÑOS; DE MEDIAR CIRCUNSTANCIAS ATENUANTES, PODRÁ SER REDUCIDA HASTA UN MÍNIMO DE DOS
(2) AÑOS.”



           Producer (Signature)                        Date                                     Signature of Applicant




SSS 477 (03/04)                                                                                 Page 5 of 5

				
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