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PSD 12 10 Page 1 of 9

ADMIRAL INSURANCE COMPANY

PHYSICIANS AND SURGEONS

PROFESSIONAL LIABILITY APPLICATION

(CLAIMS MADE COVERAGE)

1. Full Name of Applicant: _______________________________________________________________________

2. Principal Office Address: ______________________________________________________________________

County:_____________________________________________________________________________________

3. Home Address:______________________________________________________________________________

____________________________________________________________________________________________

4. Social Security #: ________________________________ DEA #: __________________________________

5. List the States and License Numbers where you practice:____________________________________________

____________________________________________________________________________________________

6. Date of Birth: __________________ Place of Birth: ________________________________________________

7. Are you a U.S. Citizen? _____ Yes _____ No If NO, please indicate your status and date of entry into the

United States:________________________________________________________________________________

8. What is your medical or surgical specialty: _______________________________________________________

What percentage of your practice is dedicated to this specialty? ______________________________________

9. What is your sub-specialty:_____________________________________________________________________

What percentage of your practice is dedicated to this specialty? ______________________________________

10. Do you limit your practice to the above specialties? _____ Yes _____ No If No, what other specialties do you

practice? Provide details. ______________________________________________________________________

____________________________________________________________________________________________

11. Are you American Board certified? _____ Yes _____ No

Medical Specialty: ______________________________ Date Certified: ______________

Medical Specialty:_______________________________ Date Certified: _____________

12. Type of Practice (check all that apply)

_____ Individual _____ Employee _____ Member of Multi-person Corp or Assoc

_____ Individual Corporation _____ Partnership _____ Other_____________________________

13. What is your total annual revenue? ____ $100,000 or less ____$250,001-$499,999

____ $100,001 - $250,000 ____$500,000 or more

14. Please provide the names of all facilities that you practice at and your interest in each facility.

Name of Clinic or Facility and Location

Interest (Owner, Partner, Employee?)

___________________________________________________________________________________________

*Attach a separate attachment if necessary.

15. Are you seeking coverage for your work at all of the above facilities? _____ Yes _____ No If No, please list

those facilities for which you do not require coverage and explain why coverage isn’t needed. ____________

___________________________________________________________________________________________

16. Please provide the number of professionals you employ or contract with and whether or not they carry their

own individual medical malpractice coverage.

Submit Application

PSD 12 10 Page 2 of 9

Carry their own

Employed

Contracted Med Mal policy?

Physicians ________ ________ ____ Yes ____ No

Physicians Assistants ________ ________ ____ Yes ____ No

Nurse Practitioners ________ ________ ____ Yes ____ No

Surgical Technicians ________ ________ ____ Yes ____ No

CRNA’s ________ ________ ____ Yes ____ No

Chiropractors ________ ________ ____ Yes ____ No

RN’s ________ ________ ____ Yes ____ No

LPN’s, Nurse Aides ________ ________ ____ Yes ____ No

Other: ______________________ ________ ________ ____ Yes ____ No

*Please attach copies of dec pages on above professionals that carry their own malpractice policies.

17. Are all of the above individuals licensed in accordance with applicable state and federal regulations?

_____ Yes _____ No If NO, please attach explanation.

18. List the hospitals at which you are currently a staff member: ________________________________________

____________________________________________________________________________________________

19. Briefly describe the type and extent of your hospital privileges:_______________________________________

____________________________________________________________________________________________

20. Are you the Chief or Head of a hospital department? _____ Yes _____ No If YES, which department(s):

____________________________________________________________________________________________

21. Are you the medical director of a nursing home or assisted living facility? If so, please provide the name of

the facility:

_____________________________________________________________________________________________

22. Are you the medical director of any other facilities? If so, please provide the names of each facility:

_____________________________________________________________________________________________

23. From what Medical School did you graduate? ____________________________________________________

City, State and Country of Medical School _______________________________________________________

Degree: _______________________________________________ Year of Graduation: ____________

If foreign medical school graduate, are you certified by the Educational Council for Medical School

Graduates? _____ Yes _____ No. If YES, state the year: ___________

24. Internship? _____ Yes _____ No If Yes, complete the following:

Location: ____________________ Dates: From ___________ To ___________

Type: _______________________ Completed? _____ Yes _____ No

25. Residency? _____ Yes _____ No If YES, complete the following for each:

Location: ____________________ Dates: From ___________ To __________

Type: _______________________ Completed? _____ Yes _____ No

Location: ____________________ Dates: From ___________ To __________

Type: _______________________ Completed? _____ Yes _____ No

26. Where have you practiced your profession since completion of training:

In _________________________________________________ From _______ To _______

PSD 12 10 Page 3 of 9

27. Additional Medical Training? _____ Yes _____ No If Yes, provide details including type, location, and

date of training: ______________________________________________________________________________

____________________________________________________________________________________________

28. Have you participated in any continuing medical education program(s) within the past five years?

_____ Yes _____ No If YES, please provide details: ________________________________________________

____________________________________________________________________________________________

29. Indicate memberships in professional societies: ____________________________________________________

____________________________________________________________________________________________

30. Do you perform one or more of the following: Yes No

A. Endoscopic Procedures, other than sigmoidoscopy or _____ _____

proctoscopy. If Yes, describe: __________________

__________________________________________

B. Catheterization, other than swan-ganz, umbilical cord _____ _____

or urethral catheterization or arterial line in a peripheral

vessel. If Yes, describe: ________________________

___________________________________________

C. Arteriography, lymphangiography, myelography or _____ _____

phenmoencephalography?

D. Interventional radiology-percutaneous transluminal _____ _____

angioplasty or embolization?

E. Radiation therapy, including radium implants? _____ _____

If Yes, describe: _____________________________

F. Chemobrasion or dermabrasion? _____ _____

G. Hair Transplantation or Suturing of Hairpieces? _____ _____

H. Mohs Micrographic surgery? If YES, describe: _____ _____

___________________________________________

I. Acupuncture? If YES, describe: _________________ _____ _____

J. Prenatal care and normal deliveries? If YES, _____ _____

Do you perform home deliveries? _____ _____

Do you only perform prenatal care? _____ _____

Do you supervise nurse midwives? If YES, when _____ _____

do you refer: __________ weeks gestation

K. Dilation and curettage? _____ _____

L. Needle Biopsies? If YES, describe: ______________ _____ _____

M. Electroshock therapy or hypnosis? If YES, describe: _____ _____

___________________________________________

N. Radial keratotomy, excimer laser PRK, LASIK or _____ _____

any other surgical vision correction procedure?

Do you perform any of the following? (continued) Yes No

PSD 12 10 Page 4 of 9

O. Surgery, other than incision of boils and superficial _____ _____

abscesses or suturing skin and superficial fascia?

If Yes, please attach a list of all surgical procedures.

P. Non-spontaneous, induced abortions? If YES, _____ _____

What is maximum trimester?___________________

Q. Vasectomies or reversal of vasectomies? _____ _____

R. Hysterectomies? If YES, do you perform laparoscopic _____ _____

hysterectomies? _____ _____

S. Cholecystectomies? If YES, do you perform laparoscopic _____ _____

cholecystectomies? _____ _____

If YES, how many performed as of this date: ________

T. Tonsillectomies and/or Adenoidectomies? _____ _____

U. Caesarian sections? _____ _____

V. Spinal Surgery? If you also perform chemonucleolysis, _____ _____

check here: ____ and/or percutaneous lumbar

disectomy, check here: _____

W. Administration of general, spinal or caudal block _____ _____

anesthesia?

X. Open reduction of fractures? _____ _____

Y. Organ transplantation? If YES, describe: ____________ _____ _____

________________________________________________

Z. Sex Change Operations? _____ _____

AA. Weight Reduction Surgery including gastric bypass or

other stomach banding procedures? If YES, which

procedures? __________________________________ _____ _____

____________________________________________

BB. Experimental research, surgical research, or experimental _____ _____

therapy in human patients? If YES, describe:_________

CC. Cosmetic/Plastic Surgery? If YES, complete the following: _____ _____

Do you perform breast augmentation? _____ _____

Do you perform breast reductions? _____ _______

Do you perform liposuction? If YES, what is the _____ _____

maximum amount of cc’s removed? ________________

Do you perform fat recycling? If YES, in what parts _____ _____

of the body? ___________________________________

Do you perform vaginoplasty or labiaplasty? _____ _____

Do you use silicone implants? If Yes, in which parts _____ _____

of the body: ___________________________________

Do you perform Botox injections? If Yes, in which parts _____ _____

of the body: ___________________________________

DD. Penile lengthening or enhancement procedures? _____ _____

Do you perform any of the following? (continued) Yes No

PSD 12 10 Page 5 of 9

EE. Do you perform Pain Management Procedures? _____ _______

If so, please indicate the procedures you perform:

CATEGORY A:

Acupuncture _____ _____

Botox Injections _____ _____

Medication Only _____ _____

Massage/Osteopathic Manipulation – No Anesthesia _____ _____

Medicinal Marijuana – Prescription Only – No Dispensing _____ _____

CATEGORY B:

Facet Joint Blocks _____ _____

Lesioning _____ _____

Percutaneous Discectomy _____ _____

Percutaneous Endoscopic Nerve Root Decompression _____ _____

Peripheral Nerve Block _____ _____

Radio Frequency Nerve Ablation _____ _____

Rapid Opiate Detoxification _____ _____

Selective Nerve Root Block _____ _____

Sympathetic Blocks _____ _____

Trigger Point Injections _____ _____

Schedule I or Schedule II Prescription Medications _____ _____

CATEGORY C:

Dorsal Column Stimulator Implants/Reprogramming _____ _____

Epidural or Spinal Catheters _____ _____

Intradiscal Electrothermal Therapy _____ _____

Peripheral Nerve Stimulation _____ _____

Spinal Infusion Implants/Pumps; Removal, Refilling/Reprogramming

_____ _____

Spinal Manipulation under General Anesthesia _____ _____

Vertebroplasty _____ _____

Discectomy _____ _____

FF. Any other surgical procedures not shown above? _____ _____

Please describe.________________________________________________________________________________

_____________________________________________________________________________________________

*PLEASE ATTACH A LIST OF ALL SURGICAL PROCEDURES YOU PERFORM

31. Do you perform surgery in your office? _____ Yes _____ No If YES, please list. ________________________

____________________________________________________________________________________________

32. Do you perform surgery in other non-hospital facilities? _____ Yes _____ No (If YES, what type of facility and

list the surgical procedures: ________________________________________________________

________________________________________________________________________________

33. In the course of surgery does a Board Certified Anesthesiologist provide the anesthesia? _____ Yes _____ No

If No, please provide details. _______________________________________________________

________________________________________________________________________________

34. Do you do any hospital emergency room work? _____ Yes _____ No If YES, Is the emergency room care:

Only for your own patients? _____ Yes _____ No

Required for staff privileges? _____ Yes _____ No

How many hours per month: _________________

Does the hospital cover you for malpractice while you work in the emergency room? _____ Yes _____ No

Are you requesting coverage for your emergency room work? _____ Yes _____ No

PSD 12 10 Page 6 of 9

35. Do you assist in surgery:

On your own patients? _____ Yes _____ No

On patients of others? _____ Yes _____ No

36. If your practice includes plastic surgery, specify the percentage of your practice devoted to:

_____% Traumatic Surgery _____% Cosmetic/Elective Surgery

37. If your practice includes weight reduction/control (other than by diet and exercise), specify the percentage of

patients that are exclusively weight control: __________%.

Do you prescribe any weight control drugs? _____ Yes _____ No If YES, list drugs prescribed. ____________

____________________________________________________________________________________________

Do you dispense supplements for weight control? _____ Yes _____ No If Yes, list supplements dispensed. ___

____________________________________________________________________________________________

Do you use injections for weight control? _____ Yes _____ No If YES, list drugs injected:_________________

____________________________________________________________________________________________

38. Have you or any of your employees: (If yes, attach details.) Yes No

A. Ever been the subject of investigative or disciplinary _____ _____

proceedings or reprimanded by a governmental or

administrative agency, hospital, or professional

association? Attach a copy of Complaint and Consent

Order document if applicable.

B. Ever been convicted for an act committed in violation _____ _____

of any law or ordinance other than traffic offenses?

C. Ever been treated for alcoholism or drug addiction or _____ _____

undergone personal psychiatric treatment or has any

administrative agency, hospital or professional association

requested or required you be evaluated for an alleged

mental condition and/or alcohol or drug addiction?

D. Ever had any state profession license or license to _____ _____

prescribe or dispense narcotics refused, suspended,

revoked, renewal refused or accepted only on special

terms or ever voluntarily surrendered same?

E. Ever had any professional liability insurance cancelled, _____ _____

declined, refused to renew or accepted only on special

terms?

F. Ever failed any medical licensing or specialty organization _____ _____

examination?

G. Do you have any chronic illnesses or defects? If Yes, _____ _____

please describe. ________________________________

39. Do you supervise any individuals other than your own employees? _____ Yes _____ No If YES, please provide

detailed explanation of your responsibilities, relationship and whether or not these individuals have their own

medical malpractice coverage: __________________________________________________________________

____________________________________________________________________________________________

PSD 12 10 Page 7 of 9

40. Are you under contract to any individual, firm or corporation other than your own? _____ Yes _____ No

If YES, attach explanation including details of responsibilities. If this contract contains a hold harmless

agreement then attach a copy of the contract language.

41. Are you in the employ of, or under contract to any governmental entity? _____ Yes _____ No If YES, please

provide details and outline your duties.___________________________________________________________

____________________________________________________________________________________________

42. Do you offer professional advice to the public such as through a website, radio or TV broadcasts, newsletters,

etc? _____ Yes _____ No If YES, please provide details. _____________________________________________

____________________________________________________________________________________________

43. Do you advertise your professional services in any manner other than a simple listing in a telephone

directory? _____ Yes _____ No If YES, please provide details and attach copies of all advertising brochures.

____________________________________________________________________________________________

44. Are you associated with any agency or organization that engages in any kind of advertising for, or solicitation

of patients? _____ Yes _____ No If YES, please provide details. ______________________________________

____________________________________________________________________________________________

45. Average Weekly Patient Load: ____________________ Total Patients Annually: ______________________

Total surgeries performed annually: ____________________

46. Average number of hours worked per week: ____________________

47. Do you anticipate any changes in your practice? _____ Yes _____ No If YES, please describe: _____________

____________________________________________________________________________________________

48. List the prior medical malpractice insurance carried for each of the past 5 years beginning with most current:

INSURANCE LIMITS OF POLICY PREMIUM

RETRO DATE

COMPANY

LIABILITY PERIOD

____________________________________________________________________________________________

*Attach a copy of the declarations page of your most recent policy.

49. Do you own, operate or provide professional services for, or at, any health care facility or business enterprise

not already clearly described in this application? _____ Yes _____ No If YES, please describe: ___________

____________________________________________________________________________________________

50. Has any claim or suit for alleged malpractice been brought against you?_____ Yes _____ No

If YES, how many total claims or incidents: _____________

Please complete the Supplemental Claim Information Form attached to this application for each and every

claim. Also, please attach 10 years of currently valued company loss runs.

51. Has any claim or suit for alleged malpractice been made against you that has NOT been reported to a prior

insurer? _____ Yes _____ No If Yes, please complete the Supplemental Claim Information Form attached to

this application for each and every claim.

52. Are you aware of any acts, errors, omissions or circumstances which may result in a malpractice claim or suit

being made or brought against you? _____ Yes _____ No If Yes, please provide details including name of

claimant, date of occurrence, date of first contact, allegation and current status of incident.

PSD 12 10 Page 8 of 9

The applicant declares that the above statements and representations are true and correct and that no facts have

been suppressed or misstated. The completion of this application does not bind the Company to sell nor the

applicant to purchase this insurance, but any subsequent contract issued will be in full reliance upon the statements

and representations made in this application and this application will be made a part of the policy. The applicant

understands that any subsequent contract issued by the Company will be issued on a claims made form.

________________________________________________ ________________________

Signature of Applicant Date

Please attach the following documents to this application:

 C.V. or resume

 Five years of currently valued company loss runs

 Copies of any disciplinary actions, stipulation orders or probation documents

 Copies of declarations pages for all employees or contractors that carry their own med mal

 Copy of applicant’s most current declarations page

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PSD 12 10 Page 9 of 9

SUPPLEMENTAL CLAIM INFORMATION FORM

(Complete one form for each claim)

1. Name of applicant/named insured: ____________________________________________________

__________________________________________________________________________________

2. Name of other parties or defendants named in suit: ______________________________________

__________________________________________________________________________________

3. Date of alleged error or occurrence, or contact date: _____________________________________

4. Date claim was made: _______________________________________________________________

5. Name of claimant: _________________________________________________________________

6. Name of Insurance Company handling your claim: ______________________________________

7. Present status of claim or final disposition: _____________________________________________

__________________________________________________________________________________

Circle One: CLOSED OPEN

8. Defense costs paid to date inclusive of any deductible: ____________________________________

9. If closed, total loss paid, inclusive of any deductible: _____________________________________

10. If claim is open or pending, what are the insurers reserves?

Defense: _____________________________ Loss: ___________________________

11. Description of case and events including allegations and assessment of liability: ______________

__________________________________________________________________________________

12. Claimants last settlement demand: ____________________________________________________

__________________________________ __________________________________________

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