Docstoc

MISCELLANEOUS MEDICAL PROFESSIONAL LIABILITY

Document Sample
MISCELLANEOUS MEDICAL PROFESSIONAL LIABILITY Powered By Docstoc
					MISCELLANEOUS MEDICAL PROFESSIONAL LIABILITY.
APPLICATION FOR MISCELLANOUS MEDICAL PROFESSIONAL LIABILITY INSURANCE WITH CERTAIN UNDERWRITERS AT LLOYD’S

THIS APPLICATION IS FOR A CLAIMS MADE INSURANCE POLICY APPLICANT‟S INSTRUCTIONS 1. ALL QUESTIONS MUST BE ANSWERED COMPLETELY; PLEASE TYPE OR PRINT CLEARLY; IF ANY QUESTION ARE CONSIDERED “NOT APPLICABLE”, PLEASE EXPLAIN WHY. IF YOU NEED MORE SPACE, CONTINUE ON ATTACHMENT „A‟ & INDICATE QUESTION NUMBER. PLEASE COMPLETE THE FINANCIAL SUPPLEMENT ATTACHMENT „B‟ AND OTHER SUPPLEMENT WHERE REQUIRED. THIS APPLICATION, WHICH INCLUDES SUPPLEMENT FORMS, MUST BE SIGNED AND DATED BY PRINCIPAL OF THE FIRM.

2. 3. 4.

1. Name of Applicant:_________________________________________________________________ 2. Address:_________________________________________________________________________ City:_________________________________ County:_____________________________________ State_________________________________Zip:_________________________________________ 3. Telephone:_____________________Facsimile:_________________E-Mail____________________ 4. Please describe in detail the nature and type of the professional services for which coverage is desired and indicate the percentage of revenue derived for each. ___________________________________________________________________________________ ___________________________________________________________________________________ 5. In the past 24 months has the Applicant or any of its principals engaged in any business or profession other than as described in the above question? YES__________ NO__________

If yes, please explain: ___________________________________________________________________________________ ___________________________________________________________________________________ 6. Please indicate type of company: Sole Trader _____ Non-profit _____ Partnership _____ Corporation _____ Privately Held _____

Publicly Traded _____

Other ___________________________

7. 8.

Date established:______________________________ Is the Applicant controlled or owned by, or associated or affiliated with, or does it own, any other firm or business enterprise? YES _____ NO _____

If yes, please explain:______________________________________________________________ _______________________________________________________________________________ 9. Are any significant changes in the nature or size of the Applicant‟s business anticipated over the next 12 months? Or have there been any such changes in the past 12 months? YES_____ NO _____

If yes, please explain:______________________________________________________________ _______________________________________________________________________________ 10. Has the Applicant ever been cited for any violation of Federal, State or local licensing requirements for operation? YES_____ NO _____

If yes, please explain:_____________________________________________________________ _______________________________________________________________________________ 11. Staff Number Principals Professional Non Professional Other Total Please describe duties of the above ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 12. Please list professional Associations to which the Applicant belongs:________________________ ___________________________________________________________________________________ 13.Gross billings: This year (est):_____________ Last Year:___________ Year prior:_________

14. Does the Applicant use a written contract: Always: _____ Sometimes: _____ Never: _____

If not always, please explain how the scope of services to be provided is agreed:_______________ _______________________________________________________________________________ 15. Does the Applicant offer advice to any client in respect of the client‟s medical, mental or emotional conditions or the client‟s relationship with other people? YES:_____ NO: _____ If yes, please explain Does the Applicant perform credentialing of health care providers? If yes, then please answer all questions in this Section. Does the applicant provide credentialing services to others for a fee? If yes, please provide total fees charged: Last 12 months: $____________ Next 12 months $____________ YES: _____ NO: _____ YES: _____ NO: _____

16. Does the Applicant directly or indirectly access any available provider data banks during the credentialing process? YES: _____ NO: _____ If yes, please identify the data bank (s) ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 17. Does the applicant sub-contract work to others? YES: _____ NO: _____

If yes, please explain and include the nature of indemnities, hold harmless agreements, etc: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 18. Does the Applicant have a written procedures manual for employees to follow? YES: _____ NO: _____ 19. Does the Applicant have a formalised training program for employees? YES: _____ NO: _____

20. Please give details of professional liability insurance in favour of the Applicant currently in force: YES: _____ NO: _____ If yes, please indicate professional liability insurance carried for each of the past three years. Carrier From To Limit Deductible Premium Retrodate

_______________ ___/___ ___/___ _________ ____________ ____________ ____________ _______________ ___/___ ___/___ _________ ____________ ____________ ____________ _______________ ___/___ ___/___ _________ ____________ ____________ ____________ _______________ ___/___ ___/___ _________ ____________ ____________ ____________

20: Has the Applicant or any director, officer, employee, or partner provided professional services on behalf of the Applicant been subject to disciplinary action or investigative procedures by a governmental or administrative agency, hospital, or professional association? YES: _____ NO: _____

Ever been convicted for an act committed in violation of any law or ordinance other than traffic offences? YES: _____ NO: _____

Ever been treated for alcoholism or drug addiction? YES: _____ NO: _____

Ever had any state professional licence or licensee to prescribe or dispense narcotics refuse suspended, revoked renewal refused or accepted only on special terms or every voluntarily surrendered game? YES: _____ NO: _____

Have any errors and omissions or professional liability insurance ever been declined or cancelled? YES: _____ If Yes, please explain ___________________________________________________________________________________ ___________________________________________________________________________________ 21. Is the applicant aware of any errors, omissions or claims (including any circumstances reported to previous insurers which have not developed into claims) during the last ten years? YES: _____ NO: _____ NO: _____

If yes, please complete attachment „c‟. 22. Has the applicant been a party to any lawsuit or other legal proceeding within the past five years? YES: _____ NO: _____ If yes, please provide (on attachment „A‟) a description which includes the venue of the action, the parties, the amount at dispute, the nature of the claim(s), the status of the action(s) and how the action(s) was resolved as to the applicant, including all costs incurred; including defences expenses.

23. The basic policy for which you have applied will not cover acts, errors or omissions which took place prior to the inception date of the policy. If you desire a quote for these prior to acts, please enter the date from which you want prior acts covered __________________________ (Note that coverage does not apply to known or expected claims, or those which aany insured should have forseen.) 24. Limit required: ($) 500,000_____ 1,000,000_____ 2,000,000_____ 5,000,000_____ OTHER __________________

Deductible: ($) 2,500_____ 5,000_____ 10,000_____ 25,000_____ 50,000_____

OTHER__________ ALL WRITTEN STATEMENT AND MATERIALS FURNISHED IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF. THIS APPLICATION DOES NOT BIND THE APPLICANT TO BUY, OR THE COMPANY TO ISSUE, THE INSURANCE, BUT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BE ATTACHED TO AND MADE PART OF THE POLICY. THE APPLICANT FURTHER DECLARES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE TIME WHEN THE POLICY IS ISSUED, THE APPLICANT WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES, AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORISATION OR AGREEMENT TO BIND THE INSURANCE. NOTICE; IN CERTAIN STATES, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANT FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS ACRIME. I HAVE READ THE FORGOING APPLICATION OF INSURANCE INCLUDING SUPPLEMEMNT SHEETS „A‟, „B‟ AND‟C‟ AND WARRANT THAT THE RESPONSES PROVIDED ON BEHALF OF THE APPLICANT ARE TRUE AND CORRECT.

SIGNED THIS ___________DAY OF ___________2000 IN ___________

APPLICANTS SIGNATURE : __________________________________________________ ADDRESS : ______________________________ ______________________________ ______________________________ E.MAIL
DATE :

TITLE : ______________________

______________________________
_________________________

IT IS ESSENTIAL THAT THE APPLICATION IS SIGNED AND DATED WITHIN 30 DAYS OF REQUESTED INCEPTION

MISCELLANEOUS MEDICAL PROFFESIONAL LIABILITY ATTACHMENT „A‟

SIGNED : _________________________________

DATE : _____________________

MISCELLANEOUS MEDICAL PROFFESIONAL LIABILITY ATTACHMENT „B‟

FINANCIAL SCHEDULE

Please provide the following information concerning the current year estimated financial figures and two previous years :

Name of Applicant: _______________________________

Date: __________________

19________ $
TOTAL REVENUES TOTAL GROSS ASSETS TOTAL CAPITAL (EQUITY) TOTAL DEBT SHORT TERM DEBT (due within One year) TOTAL LONG-TERM DEBT TOTAL ESTABLISHED CREDIT LINES WITH BANKS NET INCOME AFTER TAX DEPRECIATION/AMORTIZATION Any further details you may wish to include : maximum minimum __________ __________ __________ __________ __________ __________ __________

19_______ $
__________ __________ __________ __________ __________ __________ __________

2000 $
__________ __________ __________ __________ __________ __________ __________

__________ __________ __________

__________ __________ __________

__________ __________ __________

___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

SIGNED : ______________________________

DATE : ______________________

MISCELLANEOUS MEDICAL PROFESSIONAL LIABILITY ATTACHMENT „C‟
Please complete this form if the applicant is aware of any errors, omissions or claims as indicated in question 21 of the Application Form (including any circumstances reported to previous insurers which have not developed into claims) during the last ten years. 1.Name of Applicant : ________________________________________________________________ 2.Name of Member of Staff involved in claim : ____________________________________________ 3.Name of (potential) claimant : ________________________________________________________ 4.Date of Incident : ___________________ 5.Under which policy was the claim made? Date claim made : ________________________ Carrier : ________________________________ Policy No: ______________________________ 6. Status of Claim : Closed: _____ or Open: _____ Please indicate total loss ___________________ Please complete questions 7,8,9 & 10

7. Total defence costs and expenses to date : _______________________________________________ 8. Damages or other relief south by the claimant(s) : ________________________________________ 9. Insurers loss return : ________________________________________________________________ 10.Please…………….the following details : i) ii) iii) the specific act, error or omission upon which the claimant bases the claim. a brief description of the claim. Details of the current status and proposed strategy for handling the claim.

___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Please continue overleaf if necessary…….

SIGNED : _________________________________

DATE : ________________


				
Lingjuan Ma Lingjuan Ma
About