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WILL BE PSA PHYSICIANS SURGEONS APPLICATION cosmetic surgery

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					                                     PHYSICIANS APPLICATION
                                   FOR PROFESSIONAL LIABILITY
                                     CLAIMS MADE INSURANCE



Complete this application in ink. Answer all questions. If a question is not applicable to your practice, indicate NOT
APPLICABLE. If the answer is NONE; so state. If space is not sufficient to fully answer a question, use letterhead to
complete your answers.

    PLEASE ATTACH A COPY OF YOUR *CURRENT DECLARATIONS PAGE AND BUSINESS LETTERHEAD

PERSONAL INFORMATION:


NAME (include professional designation)



BUSINESS NAME (if different from physician name)



BIRTH DATE                                                  SOCIAL SECURITY NUMBER



PRIMARY PRACTICE ADDRESS                             CITY                    STATE             ZIP    COUNTY


TELEPHONE:        (   )                                      FAX:   (   )



HOME ADDRESS                                         CITY                    STATE             ZIP    COUNTY

ADDITIONAL PRACTICE LOCATIONS:


STREET ADDRESS                                       CITY                    STATE             ZIP    COUNTY


STREET ADDRESS                                       CITY                    STATE             ZIP    COUNTY


COVERAGE:

A.    DESIRED EFFECTIVE DATE: ______________________________________________ _________

B.    DESIRED LIMITS OF LIABILITY: $__         _______________________ / $_________________________

C.    IF PRIOR ACTS COVERAGE IS DESIRED, PLEASE PROVIDE CURRENT PRIOR ACTS DATE: ________

D.    IF CURRENTLY INSURED BY A CLAIMS-MADE POLICY AND DO NOT WISH PRIOR ACTS COVERAGE,
      HAVE YOU OBTAINED EXTENDED REPORTING (TAIL) COVERAGE FROM YOUR CURRENT CARRIER?
          YES      NO   If yes, please provide a copy.


MEDICAL TRAINING AND HISTORY:
A.    MEDICAL SPECIALTY: _________________________________PERCENT OF PRACTICE: _______%
      SUB-SPECIALTY: _____________________________________PERCENT OF PRACTICE: _______%




                                                                                                               Page 1 of 6
B.     MEDICAL EDUCATION:
Medical School: Institution                                              State        From                   Completed?
                                                                                      To

Internship: Institution                                                  State        From                   Completed?
                                                                                      To

Residency: Institution                 Specialty                         State        From                   Completed?
                                                                                      To

                                                                         State        From                   Completed?
                                                                                      To

                                                                         State        From                   Completed?
                                                                                      To


C.     DATE AND LOCATION YOU BEGAN PRACTICING: ____________________________________________

D.     IF YOU ARE A GRADUATE FROM A FOREIGN MEDICAL SCHOOL:
               -are you certified by the Education Council for Medical School Graduates?        No        Yes
               -have you passed FLEX?                                                         No          Yes

E.     DESCRIBE ANY CONTINUING MEDICAL EDUCATION COURSES THAT YOU HAVE COMPLETED WITHIN THE
       LAST TWO YEARS:



F.     ALL MEDICAL LICENSE INFORMATION:
                 STATE              LICENSE NUMBER                           EXPIRATION DATE              STATUS




G.     NARCOTICS/DEA LICENSE #:_________________________STATUS:___                     __________________

H.     MEDICAL ASSOCIATIONS/SOCIETIES OF WHICH YOU ARE A MEMBER:

          1.      COUNTY
          2.      STATE
          3.      NATIONAL

I.     BOARD CERTIFICATION INFORMATION:
                                    NAME OF BOARD                                CERTIFIED           QUALIFIED
                                                                                 No          Yes     No       Yes
                                                                                 No          Yes     No       Yes
                                                                                 No          Yes     No       Yes


J.          HAS YOUR PRACTICE CHANGED SIGNIFICANTLY IN THE LAST FIVE YEARS?                          No         Yes
         If YES, please explain


INSURANCE HISTORY:
A.   Please provide the following information regarding your professional liability insurance for the past five years:
B.   Please explain any gaps in coverage:
CARRIER                        CLAIMS-MADE OR        LIMITS OF LIAB.     POLICY TERM           IF CLAIMS-MADE WAS        Deductible OR Self
                               OCCURRENCE                                                      TAIL PURCHASED?           Insured Retention




                                                                                                                                Page 2 of 6
PROFESSIONAL HISTORY:
     Please answer the following questions and include a narrative explanation of all “yes” answers on a copy of your business
     letterhead:

      1)        Has any claim or suit for alleged malpractice ever been brought against you? If yes,                 No      Yes
                complete the attached Supplemental Claim Form for EACH claim.
                Are you aware of any circumstances that might lead to a claim or suit?                               No      Yes
      2)        Has this information been reported to a prior insurance carrier? Please complete the
                                                                                                                     No      Yes
                attached Supplemental Claim Form for EACH incident.
      3)        Has your insurance for medical professional liability ever been canceled, suspended, non-            No      Yes
                renewed or declined for reasons other than an insurer withdrawing from the state?
      4)        Has your board certification or membership in any medical society/association ever                   No      Yes
                been refused, suspended, revoked, put on probation or voluntarily surrendered?
      5)        Has your medical or narcotics license ever been suspended, denied, revoked, put on                   No      Yes
                probation or restricted by a state licensing board in any state?
      6)        Have any fee or professional relations complaints been registered against you with your              No      Yes
                medical association(s), hospital(s) or state licensing authority?
                Have you ever been diagnosed with, or treated for, alcoholism, drug addiction, mental or
      7)        chronic physical illness? If yes, provide date of illness and provide a statement from your          No      Yes
                treating physician attesting to your fitness to practice medicine.
      8)        Have you ever been indicted in a criminal suit?                                                      No      Yes

      9)        Has any claim or suit for alleged sexual misconduct ever been brought against you?                   No      Yes
      10)       Have Medicare and/or Medicaid authorities ever brought charges against you?                          No      Yes

CURRENT PRACTICE:
A.   Number of years at your current location:                 If less than 5 years, provide previous locations and dates of practice.




B.   Indicate number of practice hours per week:________ Average patient load: ______weekly _________annually.

C.   For what percentage of your total patient count do you act in a “gatekeeper” position [ that is the authorizing and/or rejecting of
     requests for hospitalization or specialized treatment(s), and/or determining the length of hospitalization or specialized treatments for
     or on behalf of any organization(s)] for an HMO, PPO or similar Managed Care Organization ]? ________%

D.   Do you practice teleradiology or any other type of telemedicine by electronic communicati on methods including but not limited to
     the internet, or do you intend to do so within the next year?   No       Yes If YES, please fully explain on your letterhead.

E.   Percentage of practice outside your primary state:      % Indicate state(s)_____________________________________



F.   Percentage of practice devoted to locum tenens work: ________%

G. Type of Practice:
                SOLO PRACTITIONER
                PARTNERSHIP                     Name
                GROUP                           Name
                EMPLOYEE                        Of
                SPACE SHARING                   With
                INDEPENDENT CONTRACTOR          For
           Indicate all other physicians/surgeons who practice in your office or group: _____ ______________________



           Are patients of the above named practice able to select their physician/provider in the group?          No       Yes

H.   Do you have any medically related duties that are insured by another company or for which you do not desire coverage though
     this application? No        Yes If yes, explain ____________________________________________________________


                                                                                                                                  Page 3 of 6
I.   Support Staff:
                                             NUM BER                                                             NUM BER
      MIDWIFE                                                                MEDICAL LAB TECHNICIAN
      NURSE ANESTHETIST                                                      PHARMACIST
      NURSE PRACTITIONER                                                     NURSE (RN & LPN)
      OR TECHNICIAN (IN OR)                                                  OR TECHNICIAN (NOT IN OR)
      SCRUB NURSE (IN OR)                                                    SCRUB NURSE (NOT IN OR)
      PARAMEDIC                                                              X-RAY TECHNICIAN
      PHYSICIAN ASSISTANT                                                    PHYSICAL THERAPIST
      SURGEON ASSISTANT                                                      OTHER (PLEASE LIST)
      Do You Supervise Any Individuals Other Than Your Own Employees? If Yes, explain.                          No      Yes



J.   Business Associations:
     1.   Indicate which, if any, of the following relationships comprise a part of your practice:
                                                                                 % OF PRACTICE
                                                          NAM E                                          RELATIONSHIP
           COMMERCIAL ENTERPRISE
           GOVERNMENTAL BODY
           MILITARY SERVICE
           EDUCATIONAL INSTITUTION
           PROFESSIONAL SPORTS TEAM
           BED & BOARD FACILITY
           URGENT CARE FACILITY
           COMMERCIAL LAB
           ADMINISTRATIVE POSITION
           SURGICENTER
           ABORTION CLINIC
           W ALK-IN CLINIC
           BIRTHING CENTER

     2.   Are you under contract in any capacity (other than your own practice) involving the practice of medicine? No           Yes
          If YES, explain: ____________________________________________________ _______________________



     3.   Do you or your PA, PC, PTP own, (wholly or in part), operate or administer any hospital, nursing home or other institution
          where medical services are customarily rendered?      No       Yes -provide details_________________                 ___



     4.   Do you participate in any activity which offers professional advice to the public, (e.g., newspaper columns, broadcasts, etc. )?
            No       Yes -explain ________________________________________________ ___________________



HOSPITAL PRIVILEGES:

          1.   Please complete the following:
                NAME OF HOSPITAL                             CITY, STATE                     NATURE OF PRIVILEGES




     If you do not currently have hospital privileges, attach the protocol you have in place if your patient requires hospital
     admission including the names of physicians willing to accept your patients for admission.


                                                                                                                              Page 4 of 6
           2.   Have your hospital privileges ever been suspended, denied, revoked, restricted or placed in probationary status?
                No     Yes - explain____________________________________________________________________


           3.   Are you the chief or head of any hospital department?      No      Yes -provide details _________________


           4.   Do you work as a medical director outside of your own practice?     No       Yes -provide details



     5.    Do you work in the emergency room, other than to fulfill requirements for your hospital privileges?      No   Yes –
           hours per week________


SURGERY:

     Please list all surgeries performed:

     ________________________________________________                     _____ number per year

     ________________________________________________                     _____ number per year

     ________________________________________________                     _____ number per year

     ________________________________________________                     _____ number per year

     ________________________________________________                     _____ number per year

     ________________________________________________                     _____ number per year


A.   Do you assist in surgery?      No      Yes -complete the following:
                                             APPROX. # ANNUALLY
                 ON YOUR OWN PATIENTS
                 ON PATIENTS OF OTHERS

B.   Do you perform or assist in any surgical procedure, in your office or other non-hospital setting, during which general
     anesthesia is administered?   No      Yes – If Yes, please complete the following:
          Number of procedures annually:                      description:
          Anesthesia administered by:


          Do you follow ASA standards for perioperative monitoring?          No     Yes

C.   Do you perform any of the following procedures? If you answer yes to any procedure with (**), please explain fully on your
     letterhead.
       ELECTIVE COSMETIC SURGERY                      No      Yes       PERCENTAGE OF PRACTICE:        %
       ITINERANT SURGERY **                           No      Yes
       VAGINAL DELIVERIES                             No      Yes       NUMBER PER YEAR
       CESAREAN SECTIONS                              No      Yes       NUMBER PER YEAR
       DELIVERIES OUTSIDE THE HOSPITAL **             No      Yes
       ABORTIONS                                      No      Yes       PERCENTAGE OF PRACTICE:         %
       NEONATOLOGY                                    No      Yes       PERCENTAGE OF PRACTICE:         %
       PROFESSIONAL SPORTS MEDICINE **                No      Yes
       ANGIOGRAPHY/ARTERIOGRAPHY/CARDIAC              No      Yes
       CATHETERIZATION

       EXPERIMENTAL PROCEDURES **                     No      Yes
       W EIGHT-CONTROL SURGERY/DRUGS **               No      Yes       PERCENTAGE OF PRACTICE:         %




                                                                                                                            Page 5 of 6
Signature Page:


By signing this application you agree that all of this information is true and correct to the best of your knowledge.

This application is subject to the underwriter’s approval. Your completion of this application and premium payment
does not obligate the insurance company to issue you insurance coverage.


This applicant declares that the information contained in the application is true and that no material facts have been
suppressed or misstated. This applicant understands that incorrect information could void coverage.




SIGNATURE IN FULL                                                                    DATE



Name – Please Print




                                                                                                           Page 6 of 6

				
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Description: WILL BE PSA PHYSICIANS SURGEONS APPLICATION cosmetic surgery