United Medical Liability Insurance Company
A Reciprocal Risk Retention Group 6600 Westown Parkway, Suite 240 West Des Moines, IA 50266 Phone: 515-727-8699 Fax: 515-727-8698
NOTICE: This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws, rules and regulations of your State. State insurance insolvency guaranty funds are not available for your risk retention group.
Claims-Made Application for Professional Liability Insurance Professional Corporations, Professional Associations & Other Organizations
1. Name of entity requesting coverage: 2. Entity business address: Street: City: State: a. Mailing address (if different from above): b. Office telephone: c. Fax number: d. Office manager or contact person: e. Tax ID number: 3. Type of practice: (please check one) Professional Corporation Corporation 4. Limits of liability requested: 5. Requested effective date of insurance: 12:01 am. Yes Yes No No Partnership LLC Professional Associates Other (Please explain in COMMENTS section)
Zip:
County:
6. If last coverage is claims-made, will you obtain a tail from previous carrier? a. If yes, please forward a copy of the tail when available. b. If no, are you applying for prior acts coverage with UMLC? 1) Retroactive date requested:
7. Beginning with your current insurer, please list all professional liability insurers. Current Carrier Prior Carrier Prior Carrier Name of Carrier Limits of Liability Occurrence or Claims-Made Dates Covered 8. Number of owners: Number of partners: a. Are all owners/partners insured with or applying for insurance with UMLIC? b. Please list all owners/partners below if applicable: Owner/Partner Specialty
Yes
No
9. Employed or contracted physicians/surgeons of your organization: Name Specialty Current Carrier
Retroactive Date
10. Furnish a list of all other professional employees of your organization (i.e., RN, LPN, PA, etc.) Name & Professional Occupation Name & Professional Occupation
11. Do any listed professional employees in Q10 carry separate professional liability insurance? Yes a. If yes, please indicate below and provide copy of declaration page: Employee Carrier Limits of Liability Policy Period
No
12. Are there any subsidiaries that provide health care related services? a. If yes, please indicate below: Subsidiary Name Description of Operations % of Ownership
Yes Date Acquired
No
13. Are the subsidiaries listed in Question 12 to be included in this coverage? 14. Does this organization perform utilization review for a fee for others? If yes, please describe: 15. Is this organization currently under contract to supervise or administrate any departments within a hospital or other facility, for an HMO or PPO, or any governmental agency or program? 16. Has this organization ever been involved in any disciplinary actions? 17. Has this organization’s license ever been suspended, restricted, revoked or surrendered or has probation ever been invoked?
***If you answered “Yes” to Questions 15, 16 or 17, please provide details in COMMENTS section.***
Yes Yes
No No
Yes Yes Yes Yes
No No No No
18.
Have any claims or suits ever been made or brought against your organization?
If yes, you must complete a Supplemental Claim Form (Form C) for each claim regardless of its outcome.
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19.
Do you have any knowledge of any claims which might be made against you or activities that might give rise to a claim or suit in the future? (Includes any request for medical records)
If yes, please provide details in COMMENTS section.
Yes
No
COMMENTS SECTION
Question Explanation(s)
I certify that the information provided in this application is true and accurate to the best of my knowledge, and that I know of no other relevant facts which might affect the underwriter’s judgment when considering this application or which might be material to the underwriter’s risk. I understand that any misrepresentation or concealment in this application will render requested coverage completely void. I further authorize the release of any underwriting or claims information from all prior and current insurers, professional societies or associations, or hospitals, to United Medical Liability Insurance Company and release from liability all individuals and organizations who provide information in good faith and without malice.
Signature Printed Name
Date
No coverage will be bound until the company has received the completed application and expressed its intention to provide coverage. Acceptance of payment in advance of review of the application is not an expression of the company’s intent to provide coverage. If the company refuses coverage, any advance payment will be returned.
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FORM C
SUPPLEMENTAL CLAIM INFORMATION FORM UNITED MEDICAL LIABILITY INSURANCE COMPANY
Complete and sign if you answered “YES” to Questions 18 on the corporation application. Please provide the information below for each claim or suit to report. 1. Physician’s name (please print): 2. Patient’s name: 3. Date of incident or occurrence from which claim resulted: 4. Date of claim: 5. Allegations made against you: 6. Was this claim reported to your insurance carrier? If yes, list name of carrier: Yes No MD DO
7. Present status or disposition of claim including amount of settlement or judgment:
8. Subsequent condition or health of patient:
9. Names of other doctors and hospitals, if any, involved in the claim or suit:
Printed Name of Applicant ______________________________
Signature of Applicant
Date
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