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Claims Made Medical Professional Liability Insurance Forehead lifts

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									                                Claims Made Medical Professional Liability Insurance
     Name:                                                                         MD/DO             Date of Birth:          /           /               .
                  First             Middle                  Last

     Social Security #:                   -             -                        FEIN #:                                                                 .

        Male       Female           Medical License #:                                                      State:                                       .

     Formal Name of Practice:                                                                  Percentage of Ownership                                  %

     Practice is a: (Mark all that apply)           Sole Proprietorship            Partnership         Corporation         Employer
                                                    Limited Liability Company                Independent Contractor
     Mailing Address:                                                                                                                                         .
                                      (street                                        city                          state                     zipcode)
     Practice Address:                                                                                         County:                                        .
                                    (street                         city            state           zip)
     Home Address:                                                                                                                                            .
                                    (street                                          city                  state                 zipcode)
     Business Phone: (                )             -                                                Home Phone: (                   )              -             .
     Business Fax: (            )               -                      E-mail:                                     @                                          .
     Website Address:                                        @                                                                                                .
     Limits:    100/300     200/600             250/750            500/1.5M       1M/3M Retroactive Date*:                                                    .
                                                                                                                            (*Required to quote prior acts)
     Current Insurer:                                                      (Required to quote) Effective Date:                                                .
     Specialty:                                         % Sub-specialty:                                               % Current Premium $                        .
     Underwriting Questions – If yes to any questions, please attach full details.
1.    Are you now being – or have you ever been – evaluated or treated for alcoholism, narcotics addiction, or mental or
      emotional illness?     Yes      No
2.     Have you every had or do you now have a physical or mental disability or other condition or circumstance that, despite
      reasonable accommodation, would limit your ability to safely practice in your medical specialty become aware of any
      chronic illness or physical defect that impairs or could impair your ability to practice your specialty? Yes      No
3.    Have you ever had professional liability insurance declined, non-renewed, cancelled, or restricted or had an involuntary
      deductible and/or surcharge assessed against you?               Yes      No
4.     Have you ever been investigated by any State Licensing Board, Narcotics Board, DEA or other governmental or
      regulatory agency or has your license to practice or your narcotics license or license to prescribe dispense drugs ever
      been denied, revoked, suspended, placed on probation, voluntarily suspended or limited in any way in any state?
         Yes       No
5.    Has any hospital, managed care organization or other healthcare organization ever restricted or revoked your privileges
      or invoked probation for any cause other than incomplete charts?    Yes       No
6.     Have you ever been indicted and/or convicted of a crime other than minor traffic violations?                                      Yes            No
7.    Have you ever been suspended, restricted or put on probation by an governmental health program (e.g. Medicare or
      Medicaid)?     Yes     No
8.    Have you been involved in a Has any claim or suit for malpractice claim, suit, or incident been made against you in the
      past 10 years?      Yes    No If “yes”, how many?                     . Please complete a Claim Information Form for
      each claim or suit.

         Signature:                                                                         Date:                                        .
NOTICE         This is an application for a claims-made policy form of professional liability insurance. The
               coverage of this policy is limited to liability only for those claims that: A) arise from incidents that
               happen while the policy is in force and that involve your professional services or the use of your
               professional office premises, and B) are first made against you and are reported to the company
               while the policy is in force during the POLICY PERIOD, unless the Extended Reporting Period
               options is exercised in accordance with the terms of the policy.
               Insurance coverage is subject to underwriting approval and payment of the initial premium billing.
               No coverage exists until the initial premium is received and a binder or Declarations Page,
               together with any endorsements that may apply, has been issued to the naked insured.

               Wood Insurance Group or the Company is authorized to make any inquire in connection with this
               application. Signed this application does not bind the Company to provide or the Application to
               purchase the insurance.

               This application, information submitted with this application and all previous applications and
               material changes thereto of which the Company receive notice is on file with the Company and is
               considered physically attached to and part of this policy if issued. Wood Insurance Group and the
               Company will have relied upon this application and all such attachments in issuing the policy. If
               the information in this application or any attachment materially changes between the date this
               application is signed and the effective date of the policy, the Application will promptly notify Wood
               Insurance Group who may modify or withdraw any outstanding quotation or agreement to bind
               coverage

INSTRUCTIONS   Please print responses in ink, and answer all questions in full. If a question does not apply to
               your practice, state “none” or “NA” (Not Applicable). Please include a copy of your letterhead and
               all of your advertisements with this application. Please indicate any additional responses on the
               Remarks Section on page 11.
               This application consists of an application for insurance, including a Remarks Section page and
               Claim Information Form. The completed application, together with any supplementary information,
               must be signed in ink and dated by the applicant in all spaces indicated. Failure to provide
               complete information will delay the processing of the application. If you purchase coverage
               and are bound this application becomes part of your permanent file with the insurer.
GENERAL
INFORMATION
              1. Social Security #_________________ 2. Corporate I.D. # (if applicable)________________

              3. Name:                                                                                    MD/DO
                                  First                Middle                    Last

ADDRESSES
              4. Practice Addresses

                 Please list all office locations where you currently practice. List primary practice office first.
                 Use the Remarks Section on page 11 to list additional locations at which you render
                 professional services.

                A. Street:________________________________________                 Bldg/Suite:_______________

                    City:__________________________ State:________________ Zip:________________

                    County:__________________ Number of years at location:______ % of practice:_               _%

                B. Street:________________________________________                 Bldg/Suite:_______________

                    City:__________________________ State:________________ Zip:________________

                    County:__________________ Number of years at location:______ % of practice:_               _%

                C. Street:________________________________________                 Bldg/Suite:_______________

                    City:__________________________ State:________________ Zip:________________

                    County:__________________ Number of years at location:______ % of practice:_               _%

              5. Billing Address other than Primary Practice

                If you require that your premium billing be sent to an address other than your primary practice
                address, please indicate.

                     Street:________________________________________               Bldg/Suite:_______________

                     City:__________________________ State:________________ Zip:________________



EDUCATION
              6. Medical School

                      Name:_________________________________________________________________

                      City:____________________ State:____________ Country:_____________________

                      Degree:_______________________ Dates:__________________________________

              7. Additional Education

                 If you have completed more than two residencies, one fellowship or other training program,
                 please provide details in the Remarks Section, page 11.
                A. Internship

                   Hospital:_____________________________________ City/State:_____________________

                   Dates:       From_______________To________________

                B. Residency

                   Hospital:_____________________________________ City/State:_____________________

                   Dates:       From_______________To________________

                C. Residency

                    Hospital:_____________________________________ City/State:____________________

                    Dates:      From_______________To________________

                D. Fellowship

                    Hospital:_____________________________________ City/State:____________________

                    Dates:      From_______________To________________

                E. Other Training

                    Hospital:_____________________________________ City/State:____________________

                    Dates:      From_______________To________________


               8. If you are a graduate of a non-U.S. medical School, are you certified by the Educational
                  Council for Foreign Medical School Graduates?                              Yes      No

SPECIALTY
               9. Primary Specialty

                  Name of Specialty:____________________________________ Percent of Practice: _____%

                  Are you board certified?         Yes      No        If Yes, Date:_______________________

                  Name of Board:______________________________________________________________

                  If not board certified, what is the expiration date of eligibility:___________________________

                  If expired, why:_______________________________________________________________
               10. Secondary Specialty

                   Name of Specialty:__________________________________ Percent of Practice: _____%

                   Are you board certified?        Yes      No          If Yes, Date:_____________________

                   Name of Board:_____________________________________________________________

                   If not board certified, what is the expiration date of eligibility:__________________________

                   If expired, why:______________________________________________________________

LICENSES &
AFFILIATIONS
               11. Licenses

                   Please specify states where you are or have been licensed.

                State       Year       License #                 Permanent        Temporary        Status*
                  State      Year         License #                 Permanent          Temporary         Status*


                  State      Year         License #                 Permanent          Temporary         Status*


                  State      Year         License #                 Permanent          Temporary         Status*


                 If any of your licenses are or have been inactive, suspended, restricted or revoked, please
                 explain in the Remarks Section on page 11.

                 12. Affiliations/Associations/Society Membership

                     A. Are you a member of any national (not specialty) medical societies? Yes  No
                         If “yes”, please list: ______________________________________________________

                     B. Are you a member of any national medical specialty societies?    Yes     No
                        If “yes”, please list: ______________________________________________________

                     C. Are you a member of any state medical society?                   Yes     No
                        If “yes”, please list: ______________________________________________________

                     D. Are you a member of any county medical society?                  Yes     No
                        If “yes”, please list: ______________________________________________________

PRACTICE
HISTORY
                 13. Are you entering practice for the first time since completing an internship, residency program,
                     fellowship or military service?                                                 Yes      No

                 14. Indicate your number of practice hours per week (include office hours, administrative
                     activities, direct patient care, surgery, consultation, etc.). Please indicate only the practice
                     hours to be insured by StarDoc: ________________

                 15. Estimate the number of patients you see on an average day of clinical practice:__________

                 16. A. Indicate number of weeks per year you practice (include office hours, administrative
                         activities, direct patient care, surgery, consultation, etc.):_________________________

                     B. If less than 26 weeks, are the weeks all consecutive?                         Yes       No

                 C. Maximum number of consecutive weeks out of
                 practice:__________________________


PRIOR PRACTICE
LOCATIONS
                 17. Where have you practiced your profession other than your
                     current practice locations? Please explain any gaps in your practice. Use Remarks
                     Section, page 11, to list additional locations.

                     A. Street:________________________________________                  Bldg/Suite:______________

                          City:__________________________ State:________________ Zip:______________

                          County:__________________ Number of years at location:_____ % of practice:_              _%


                     B. Street:________________________________________                  Bldg/Suite:______________
                    City:__________________________ State:________________ Zip:______________

                    County:__________________ Number of years at location:_____ % of practice:_               _%


                 C. Street:________________________________________                Bldg/Suite:______________

                    City:__________________________ State:________________ Zip:______________

                    County:__________________ Number of years at location:_____ % of practice:_               _%


TEACHING
             18. Are you a teaching physician?                                                 Yes       No

                 If “yes”, list name and location of school or program:________________________________

                 A. Are you responsible for supervision of residents, interns or fellows?      Yes       No

                 B. What is your compensation status?

                             Volunteer (nonpaid)           Partial Salary           Full Salary

                             Other:___________________________

                 C. Title:_____________________________

                 D. What percent of your weekly time is devoted to clinical teaching:__________________%

                 E. Does the training institution provide malpractice coverage for you?       Yes       No
                    If “No” explain in Remarks Section on page 11.

STAFF
PRIVILEGES
             19. List all facilities, including non-hospital facilities, where your have staff privileges.
                 List principal location first. Use the Remarks Section, page 11, to list additional facilities.

                 A. Facility: _____________________________ City/State: __________________________

                    Department: __________________________________ % of Practice:                              %

                 B. Facility: _____________________________ City/State: __________________________

                    Department: __________________________________ % of Practice:                              %

                 C. Facility: _____________________________ City/State: _________________________

                     Department: __________________________________ % of Practice:                             %
EMPLOYED
PERSONNEL
             20. Do you or your entity employ or contract for the services of any health care personnel in
                 the following categories. A separate application form must be submitted for each
                 category that marked with an *.

                 A. * Physician’s Assistants
                     # Employed: _______ # Contracted: _______ Insurer, if any: _____________________

                 B. * Nurse Practitioners
                    # Employed: _______ # Contracted: _______ Insurer, if any: _____________________

                 C. * Certified Registered Nurse Anesthetists
                    # Employed: _______ # Contracted: _______ Insurer, if any: _____________________

                 D. * Certified Nurse Midwife
                    # Employed: _______ # Contracted: _______ Insurer, if any: _____________________

                 E. List other paramedical personnel, including nurses, technicians, technologists, physical
                    therapists, etc.




                     # Employed: _______ # Contracted: _______ Insurer, if any: _____________________

CHANGES IN
PRACTICE
             21. Have your practice specialties/procedures, etc., changed in the past five (5) years?
                                                                                              Yes     No

                 If “yes,” please explain how the specialty/procedures, etc., have changed and give the dates
                 of changes. Use the Remarks Section, page 11, if more space is needed.




PROCEDURES
             22. If you are NOT an Anesthesiologist, do you perform:

                 A. INTRAVENOUS ANALGESIA?                                                      Yes      No

                     If “yes,” what type? _______________________________________________________

                 B. ANESTHESIA - GENERAL?                                                       Yes      No

                 C. SPINAL?                                                                     Yes      No

                 D. INTRAVENOUS?                                                                Yes      No

             23. Do you practice in any office surgical facility in which IV analgesia or general anesthetics are
                 administered?                                                                 Yes       No

                 If “yes,” list facilities: _________________________________________________________

                 A. If “yes”, is the office certified by AAAASF or AAAHC?                       Yes      No
                    If “yes”, please submit a copy of current certification, if “no,” please complete
                    supplemental surgery suite questionnaire.
24. Do you perform ELECTIVE COSMETIC SURGERY?                               Yes        No
    If “yes,” do you perform the following?

    A. BLEPHAROPLASTY?                                                      Yes        No

    B. COSMETIC SURGERY OF THE BREAST?                                      Yes        No

    C. CHEMICAL PEEL?                                                       Yes        No

       If “yes,” what type and solution strength? ____________________________________

    D. DERMABRASION/CHEMABRASION?                                           Yes        No

    E. SUCTION-ASSISTED LIPECTOMY?                                         Yes      No
       If “yes,” please provide proof of training, copy of consent form and proof of hospital
       privileges for this procedure.

    F. ENDOSCOPIC ASSISTED FOREHEAD LIFTS?                                  Yes     No
       If “yes,” please provide proof of training (12 hours of AMA category ICME credit) and
       hands-on Experience.

25. Do you practice NEONATOLOGY (treatment of critically ill or premature neonates)?
       Yes       No   If “yes,” % of practice:  %

26. Do you practice OBSTETRICS? (obstetrics includes prenatal care)         Yes        No

    A. Do you perform deliveries other than in a hospital?                  Yes        No

       If “yes,” specify facility: ____________________________________________________

    B. Do you perform obstetrical HOME DELIVERIES?                          Yes        No

27. Do you perform abortions?                                               Yes        No
    If “yes”,

    A. FIRST TRIMESTER?
       Medical                                                              Yes        No
       Surgical                                                             Yes        No

    B. SECOND TRIMESTER?
       Medical                                                              Yes        No
       Surgical                                                             Yes        No


    C. THIRD TRIMESTER?                                                     Yes        No

    D. List facilities where you perform abortions: _____________________________________
       _______________________________________________________________________
       _______________________________________________________________________

    E. Number of abortions performed per month:
       Medical _________                     Surgical:__________

    F. Do you receive referrals?                                    Yes     No
       If “yes”, from whom? ______________________________________________________
       _______________________________________________________________________

28. If you are a pathologist, do you routinely perform frozen sections and gross surgical
    PATHOLOGY examinations and then send material to an unrelated group of pathologists for
    microscopic examination and final signout?                                   Yes      No
           29. Do you perform RADIAL KERATOTOMY?                                               Yes   No

               A. SEX-REASSIGNMENT SURGERY?                                                    Yes   No

               B. WEIGHT-CONTROL SURGERY?                                                      Yes   No


           30. If you are a cardiologist, do you perform invasive procedures?                  Yes   No
               If “yes,” specify the procedure(s):




           31. If you are a dermatologist, do you make your own histopathologic diagnoses of pigmented
               lesions?                                                                  Yes      No

TYPE OF
PRACTICE
           32. What is your practice structure and your relationship, if any, with others in your practice?
                 Individual                                     Individual with DBA
                 Individual with a solo corporation             Other ______________________________

           33. Do you employ any physicians besides yourself in your practice?                 Yes    No
               If “yes,” list below with details.

           34. Do you independently contract with any entities or physicians not insured by The Doctors’
               Company?                                                                    Yes      No

               If “yes,” list below with details.

               A. If you are an independent contractor, please complete the following statement:
                  My association with _____________________________________________ is that of an
                                                    Group/Physician Name
                  Independent Contractor and the relationship conforms to the guidelines of the Internal
                  Revenue Service.

                  _____________________________________                     _______________
                                     Signature                                       Date

                   _____________________________________                    ________________
                                     Group Name                                      Carrier

                A current Declarations Page or Certificate of Insurance for the above group must be
                attached.

           35. Are you employed by any physicians or entities not insured by the company?
                                                                                        Yes No
               If “yes”, list below with details.
               __________________________________________________________________________
               __________________________________________________________________________
               __________________________________________________________________________

               If “yes” to #33, 34, or 35 indicate the names and addresses of all such groups, clinics,
               professional corporations, partnerships, commercial enterprises, government or public
               entities. Show the date of affiliation, status of employment, hours worked (weekly), number
               of physicians at each of the entities, percentage of your practice this represents, and if
               malpractice insurance is provided for this work. If more than one facility, please explain in
               the Remarks Section, page 11.
RETROACTIVE
COVERAGE
              36. If your current policy or any previous policies are claims-made and you cancel the policy
                  without purchasing an extended reporting endorsement (tail coverage) from that carrier,
                  there will be no coverage for any claim from any act or omission that took place during that
                  period of claims-made coverage. However, you may apply for a policy with a retroactive
                  date back to the first day of your previous claims-made policy. Retroactive coverage insures
                  you for claims made against you for incidents that took place while your previous claims-
                  made insurance was in effect, but that were not brought to your attention until after the
                  effective date of this policy. Retroactive coverage does not cover claims that have been filed
                  against you and/or reported to the previous insurers prior to the effective date of the policy
                  with the company. Any claims and all acts, error, omission, circumstance, or records request
                  form any attorney or incidents that could reasonably be expected to result in a claim or suit
                  MUST be reported to your present carrier prior to the requested effective date of this
                  insurance.

SIGNATURE     I have read and understand the above statement.
REQUIRED
              __________________________________________                       _____________
                              Signature                                                Date




              37. A. Will you purchase an extended reporting endorsement (tail coverage) from your current
                     insurer?                                                      Yes       No

                  B. If “no,” do you wish to purchase retroactive coverage from the company?
                                                                                            Yes         No
                      If “yes,” please complete the following:

                  C. Desired retroactive date: _______________
                     (You must attach a copy of the most recent Declarations Page from your present carrier
                     indicating the original effective date of coverage and the current paid-through date.)

                  D.   Are you, as of this date, aware of any CLAIMS or SUITS against you that have not
                       been reported to your present or prior insurer(s)?                   Yes       No

                  E. Does your current carrier consider a claim to be:
                        Report of a medical incident or         Formal demand for money

                  F. Are you or any entity proposed for this insurance aware of any act, error, omission,
                      fact circumstance, or records request from any attorney which may result
                      in a malpractice claim or suit?                                        Yes      No
                     If “yes”, how many?                     . Please complete a Claim Information Form
                      for each claim or suit .Are you, as of this date, aware of any conduct, circumstances
                      or incidents that occurred during the period of coverage listed below that
                      could reasonably be expected to result in a CLAIM, and that have not been
                     reported to your present or prior insurer(s)?                               Yes     No

SIGNATURE
REQUIRED      I hereby acknowledge that I have completed the required reporting of claims, suits and incidents
              to my current carrier.

              _____________________________________                            ______________
                              Signature                                                Date
PREVIOUS
INSURANCE
                 38. To assure that there are no gaps in coverage, please list all previous medical professional
                     liability insurance carried, beginning with your current
                     carrier. Use the Remarks Section, page 11, to list additional carriers.
                     Attach a copy of the Declarations Page from your most recent policy.

                     Current Carrier             Policy Period        Limits of Liability      Type of policy

                                                     From – To                                    Occurrence or
                                                     Mo/Day/Yr                                    Claims Made

                     1st Prior Carrier           Policy Period        Limits of Liability      Type of policy

                                                    From – To                                     Occurrence or
                                                    Mo/Day/Yr                                     Claims Made

                     2nd Prior Carrier           Policy Period        Limits of Liability      Type of policy

                                                    From – To                                     Occurrence or
                                                    Mo/Day/Yr                                     Claims Made

                     3rd Prior Carrier           Policy Period        Limits of Liability      Type of policy

                                                    From – To                                     Occurrence or
                                                    Mo/Day/Yr                                     Claims Made


EFFECTIVE DATE
                 39. Desired effective date: _______________________
                                               Month/Day/Year

                 40. Current policy expires: _______________________
                                               Month/Day/Year


LIMITS OF
LIABILITY
                 41. Indicate limits of liability desired, if available:
                         $500,000/$1,500,000                             $1,000,000/$5,000,000
                         $2,000,000/$4,000,000                           $5,000,000/$7,000,000
                         Other (limits set by your state, etc., indicate amount): _____________
REMARKS
SECTION
          If additional space is needed, please use your letterhead. For “question number,” please
          indicate question number and letter, (if applicable) – “12” and “23D” for example.

              QUESTION          REMARKS
              NUMBER
                           AGREEMENT: I do hereby warrant the truth of any statements and answers mentioned
                           herein, and that I have not intentionally withheld any information that could influence the
                           judgment of the company in considering this application for professional liability insurance.
                           Erroneous information and/or material misrepresentation will cause immediate rescission of my
                           insurance coverage.

                           AGREEMENT: I understand that the policy being applied for does not cover the liability of
                           others that I may have assumed under any contract or agreement. (Note: Your being
                           approved for coverage by the company does not imply acceptance by the company of any
                           contract or agreement or any liability assumed there under.)

                           AGREEMENT: I understand that in order to underwrite professional liability insurance, the
                           company must have access to all possible information concerning my professional conduct and
                           experience. I hereby authorize and direct any medical society, medical doctor, hospital,
                           residency program, insurance company, interindemnity arrangement, underwriter and
                           insurance agent to furnish any information concerning me or my medical practice that the
                           company may request.

                           AGREEMENT: Since I understand that the free exchange of information is essential, I agree
                           that any Person or organization furnishing information to the company pursuant to this consent
                           and direction, together with the agent, employees, or officers of such person or organization,
                           will not be liable to me in any way for furnishing such information.

SIGNATURE
REQUIRED

                             ______________________________________                                ________________
                                                 Signature                                                 Date




FRAUD NOTICE: ANY 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 FACTS MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT,
WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES, INCLUDING BUT NOT
LIMITED TO FINES, DENIAL OF INSURANCE BENEFITS, CIVIL DAMAGES, CRIMINAL PROSECUTION, AND
CONFINEMENT IN STATE PRISON.

Prior Acts Coverage Certification
The applicant hereby certifies that if Prior Acts Coverage is being requested, they have no knowledge of any professional
liability claims which have been asserted against any inured, or any affiliated professional association, corporation, or
subsidiary to which this insurance may apply, or of any occurrence, incident, or circumstance likely to result in a claim on
or after the requested initial effective date of the Prior Acts Coverage, except as described on the attached separate page.

NOTICE TO APPLICANTS: ANY 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 ACT, WHICH IS A CRIME AND MAY SUBJECT
SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO ARKANSAS AND NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY
PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR
KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS
GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
NOTICE TO COLORADO APPLICANTS: IT 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 AUTHORITIES

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE
FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF
DEFRAUDING THE INSURER OR ANY OTHER PERSON.               PENALTIES INCLUDE
IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE
BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY
THE APPLICANT.

NOTICE TO FLORIDA APPLICANTS: ANY 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 IN THE THIRD DEGREE.

NOTICE TO KENTUCKY APPLICANTS: ANY 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.

NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE
OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY
PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A
CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO MAINE APPLICANTS: IT 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 OR A DENIAL OF INSURANCE BENEFITS.

NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR
MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT
TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO NEW YORK APPLICANTS: ANY 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED
FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH
VIOLATION.

NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR
KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN
APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS
GUILTY OF INSURANCE FRAUD.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND
WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR
THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR
MISLEADING INFORMATION IS GUILTY OF A FELONY (365:15-1-10, 36 §3613.1).

NOTICE TO PENNSYLVANIA APPLICANTS: ANY 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.

NOTICE TO TENNESSEE AND VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY
PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE
COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.


I warrant to the Company, that I understand and accept the notice stated above and that the
information contained herein is true and that it shall be the basis of the policy and deemed
incorporated therein, should the Company evidence its acceptance of this application by
issuance of a policy. I authorize the release of claim information from any prior insurer to The
Wood Insurance Group Inc., 4835 East Cactus Road, Suite 440, Scottsdale, AZ 85254 or the
Company, Ten Parkway North, Deerfield, Illinois 60015



Signature                                                        Date


RETURN APPLICATION TO:
The Wood Insurance Group, Inc.
4835 East Cactus Road, Suite 440
Scottsdale, Arizona 85254                   Fax (602) 230-8207
CLAIM
INFORMATION
FORM
              Photocopy and complete this form for each additional claim. If more space is needed on
              each report, continue information on your letterhead. Please write legibly.

              1. Name of Patient: ________________________________________________________

              2. Age: __________

              3. Sex:      Male               Female

              4. Relationship to patient (e.g. attending physician, consultant, primary surgeon, assistant
                 surgeon, etc.) __________________________________________________________

              5. Allegation:______________________________________________________________
                 ______________________________________________________________________
                 ______________________________________________________________________
                 ______________________________________________________________________
                 ______________________________________________________________________

              6. Date of Incident: _____________________           Report Date: _____________________

              7. Location: _______________________________________________________________

              8. Insurance Carrier: _______________________________________________________

              9. Other Defendants: _______________________________________________________

              10. Present Status:      Open Claim          Loss of $_____________                  Settlement

                                       Closed Claim        Date Closed: ____________               Judgment

              11. Condition and diagnosis at time of incident: ___________________________________
                  ______________________________________________________________________
                  ______________________________________________________________________
                  ______________________________________________________________________
                  ______________________________________________________________________

              12. Dates and description of professional services rendered: ________________________
                  ______________________________________________________________________
                  ______________________________________________________________________
                  ______________________________________________________________________
                  ______________________________________________________________________

              13. Condition of patient subsequent to professional services (and dates of follow-up visits) if
                  known: ________________________________________________________________
                  ______________________________________________________________________
                  ______________________________________________________________________
                  ______________________________________________________________________
                  ______________________________________________________________________

SIGNATURE
REQUIRED
              I hereby declare the above information is complete and true to the best of my knowledge and
              belief:
                         ___________________________________                       ________________
                                          Signature                                         Date
Attachments required as part of your application:
 1.   Copy of your medical license for your current state of practice.
 2.   Copy of your up-to-date CV
 3.   List of all ancillary staff members/employees
 4.   Copy of ten years of insurers’ loss runs
 5.   Copy of current insurance declarations page
 6.   Copy of practice’s letterhead
 7.   Copy of your corporate entity’s Articles of Incorporation (if applicable)
 8.   Copy of any advertising and brochures used to market your practice

								
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