Fillable AH MEDICAL LAB And IMAGING 1 (Kinsale Insurance)

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AH MEDICAL LAB And IMAGING 1 (Kinsale Insurance)

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Page 1 of 9
Requesting Professional Liability:
Requested Retro Date: _________
Professional Liability Limits
Professional Liability Deductible
$100,000 / $300,000
$200,000 / $600,000
$250,000 / $750,000
$500,000 / $1,500,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$1,000,000 / $3,000,000
Other: _______________
$2,500
$5,000
$7,500
$10,000
$15,000
$20,000
$25,000
Other: _______________
Requesting General Liability:
Requested Retro Date: _________ or Occurrence Based Coverage
General Liability Limits
General Liability Deductible
$100,000 / $300,000
$200,000 / $600,000
$250,000 / $750,000
$500,000 / $1,500,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$1,000,000 / $3,000,000
Other: _______________
$2,500
$5,000
$7,500
$10,000
$15,000
$20,000
$25,000
Other: _______________
Requesting Employee Benefits Liability:
Requested Retro Date: _________
Employee Benefits Liability Limits
Employee Benefits Liability Deductible
$100,000 / $300,000
$200,000 / $600,000
$250,000 / $750,000
$500,000 / $1,500,000
$1,000,000 / $1,000,000
$1,000,000 / $2,000,000
$1,000,000 / $3,000,000
Other: _______________
$1,000
$2,500
$5,000
$7,500
$10,000
$15,000
$20,000
$25,000
Requesting Non-Owned Auto Liability:
Non-Owned Auto Liability Limits
$100,000
$200,000
$250,000
$500,000
$1,000,000
Other: _______________
*Requested coverage may or may not be offered please review any quote issued for actual terms
and conditions available. Completion of this application neither binds coverage nor guarantees
that policy will be issued.
REQUESTED COVERAGE - MEDICAL LAB INCLUDING MEDICAL IMAGING
Page 2 of 9
MEDICAL LABS AND MEDICAL IMAGING CENTERS
Instructions to the Applicant – please complete this application in ink and answer all questions completely. Attach extra
sheets as necessary should you run out of space provided. An incomplete or illegible application cannot be processed.
Completion of this application neither binds coverage nor guarantees that a policy will be issued.
• Provide a fully completed application, signed and dated by the owner, partner, or officer not earlier than 45 days
before the proposed effective date of coverage.
• If a question is not applicable, then state “N/A”.
• The following information must be submitted with the completed application:
- Copy of your current professional liability insurance Declarations Page (claims made policies must
reflect the retroactive date)
- Copy of all advertising that you use
- 5-year company loss runs, valued within the last 60 days
1. Full name of Applicant (Including DBA’s) ___________________________________________________________________
8. Date Established _____________________ Years under current management _____________
9. Applicant is a:
Individual
Professional Associations
Corporation
Partnership
LLC
Joint Venture
Other:
10. Enterprise is: For Profit Not For Profit
2. Mailing Address:______________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
3. Location Address: Check here if same as mailing:
(1) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(2) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(3) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(4) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Attach Additional Pages as Needed
4. Website Address: www._______________________________
5. Telephone: ______________________
6. Inspection/Risk Management Contact Name:
7. Inspection/Risk Management Contact E-mail:
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
GENERAL INFORMATION
Page 3 of 9
11. Please describe nature of applicant’s operations
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
12. Applicant’s operations are: Mobile Stationary
13. Please state sources and amounts of total revenue:
Source Last 12 months Next 12 months
Charitable contributions $________________ $_________________
Government Funding $________________ $_________________
Fee for services $________________ $_________________
Other – specify: $________________ $_________________
Total Gross Revenue $________________ $_________________
14. Please indicate total number of:
Tests in the last 12 months ____________________
Tests in the next 12 months ____________________
15. Please provide percentage of specimens / images:
a. Collected directly from patients ___________%
b. Received by the applicant from outside sources ___________%
16. Please provide the percentage of services provided for:
Hospitals
______%
Nursing Homes
______%
Physician offices
______%
Industrial Facilities
______%
Veterinary Clinics
______%
Other
(describe):
_________________________________________
______%
17. Please indicate the number and types of Medical IMAGING Tests performed. Check here if “None”
TYPE OF TEST
IN LAST 12 MONTHS
PROJECTED FOR NEXT 12 MONTHS
Bone Density Scan
CAT/ CT Scans
EKG/EEG
Mammograms
MRI
PET scans
Ultrasound/ Sonography
X-Ray
Other (describe):
OPERATIONS AND PROFESSIONAL ACTIVITIES
Page 4 of 9
18. Please indicate the number and types of Medical LAB Tests performed. Check here if “None”
TYPE OF TEST
IN LAST 12 MONTHS
PROJECTED FOR NEXT 12 MONTHS
Cytopathology
Histopathology
HIV / AIDS Testing
Drug or Alcohol Testing
DNA Testing to include paternity
OTHER:
(specify)
OTHER:
(specify)
19. Is the applicant involved in any of the following (explain all “yes” answers in the space provided below or additional pages
as needed):
a. Blood banking or cross matching?
YES NO
b. Manufacturing, dispensing, or testing pharmaceuticals?
YES NO
c. The use of radioactive material other than used in X-Ray
equipment?
YES NO
d. Therapy or treatment procedures?
YES NO
e. Medical, genetic, AIDS or drug research
YES NO
f. Manufacturer and/or sell laboratory equipment or supplies, reagents
or software
YES NO
___________________________________________________________________________________
___________________________________________________________________________________
20. Is the applicant involved in reading or interpreting of X-Rays, Medical images, Pathology Slides or
other similar tests? If yes, who is performing these services? Please also indicate if this is contracted or employed
individual or group.
_____________________________________________________________________ Employee Contractor
YES NO
21. If the applicant is providing any reading or interpretation services, are said results conveyed to the
patient on the applicant’s letterhead?
YES NO
N/A
22. Please indicate any accreditations or approval’s held by the applicant:
Joint Commission
CLIA Approved Lab
National Institute on Drug Abuse (NIDA) Approved
ACR accreditation
Other: ___________________________________
Other: ___________________________________
Page 5 of 9
STAFFING
23. Please provide number of employed and contracted staff:
Profession
Employed
Contracted
Full-time
Part-time
Full-time
Part-time
Lab Technicians
RN/LPN
Pathologists
Phlebotomists
Physician
(other than pathologists or radiologists)
Radiologists
X-Ray Technicians
Other: Specify
24. Are all above individuals licensed in accordance with applicable state and federal regulations?
YES NO
25. Do all physicians (employed and contracted) carry their own professional liability coverage?
If yes, what limits do they carry? ___________________
YES NO
26. Please provide the name and specialty of the applicant’s Medical Director: ________________________________________
Does the applicant’s Medical Director have direct patient care? YES NO Please specify Full Time or Part Time
27. Please indicate all of the hiring/screening procedures used for professionals and paraprofessionals who provide patient care
services at your facility:
Check of educational background, or residency program, when applicable.
Check of previous employers ( In writing By Telephone)
Criminal background check ( STATE FEDERAL)
Drug / Alcohol / Abuse Screening (circle all that are used)
Verify any pending license suspensions or revocations, or any pending disciplinary actions by other facilities.
Require information on any professional liability or work-related claim that has previously been made against any
Individual?
28. Does your facility have written job descriptions?
YES NO
Page 6 of 9
GENERAL LIABILITY - complete only if you are requesting GL coverage
29. Building Description
Buildings / Locations
#1 #2 #3 #4
Type of Construction: __________ __________ __________ __________
No. of Stories: __________ __________ __________ __________
Square Footage __________ __________ __________ __________
Date Built: __________ __________ __________ __________
Smoke detectors: Yes No Yes No Yes No Yes No
Local/Central station fire alarm: Yes No Yes No Yes No Yes No
Sprinkler System: Yes No Partial Yes No Partial Yes No Partial Yes No Partial
33. Please list professional liability insurance carried for each of the past five years
.
Insurer
Dates covered
Limits of Liability
Per claim/agg.
Deductible
Premium
Retroactive
date
34. If the applicant is currently insured under a commercial general liability policy please list coverage for the past five years.
Insurer
Dates covered
Limits of Liability
Per claim/agg.
Deductible
Premium
Occurrence or
Claims –
Made?
If the current expiring GL policy is claims-made, what is the retroactive date? _____________
30. Do any of the Applicant’s locations have any (explain any “yes” answers on page 8):
a. Exposure to flammables, explosive, chemicals?
b. Catastrophe exposure?
c. Exposure to radioactive materials?
YES NO
YES NO
YES NO
31. Has any claim for General Liability ever been made against any person(s) or entity(ies) proposed for
this insurance? If Yes, complete a supplemental claims form for each.
YES NO
32. Is (are) any person(s) or entity(ies) proposed for this insurance aware of any fact, circumstance or
situation which may result in a General Liability claim, such that would fall under the proposed
insurance? If Yes, complete a supplemental claims form for each.
YES NO
COVERAGE HISTORY
Page 7 of 9
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MARYLAND,
MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA,
OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING
APPLICANTS: In some states, 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, for the purpose of misleading, conceals information concerning any fact material thereto, may
commit a fraudulent insurance act which is a crime in many states.
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 policy holder or claimant for the
35. Has the applicant or any of its employees ever had any professional license or license to prescribe and
or dispense narcotics ever been limited, suspended, revoked, denied, or investigated by any licensing
board or regulatory agency? If yes, provide details within the supplemental information or attach
additional pages as need.
YES NO
36. Has the applicant or any of its employees ever been charged with, or convicted of a crime other than
minor traffic violations? If yes, provide details within the supplemental information or attach
additional pages as need.
YES NO
37. Has the applicant or any of its employees ever been diagnosed or treated for alcoholism, drug
addiction, any chemical dependency, or mental or chronic physical illness? If yes, provide details
within the supplemental information or attach additional pages as need.
YES NO
38. Has any claim or suit for malpractice or professional liability ever been made against the applicant OR
any other person proposed for this insurance? How Many? ______ (Complete Supplemental Claims
form for Each)
YES NO
39. Is the Applicant or any person 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?
If yes, please explain in detail, completing a supplemental claim form for each.
YES NO
40. Has any claim or suit for malpractice ever been made against the Applicant or any person proposed for
this insurance that has not been reported to the Applicant’s current or prior insurer? If yes, please
explain in detail, completing a supplemental claim form for each.
YES NO
CLAIMS AND LOSS HISTORY
FRAUD WARNING
SUPPLEMENTAL INFORMATION (reference question number if applicable)
Page 8 of 9
purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to
the Colorado Division of Insurance within the Department of Regulatory Agencies.
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 insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a
crime punishable by fines or imprisonment, or both.
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 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 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 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/she 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 a any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
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 a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE 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.
NOTICE TO 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above
statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material
facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of any
policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such
changes at our sole discretion. Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding
coverage and policy issuance. All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by
reference into this application and made a part of this application.
Applicant: _______________________________________ Title:
FEIN #: _________________________________________
Applicants Signature: _____________________________________ Date:
Agent/Broker Name:
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Page 9 of 9
If reporting more than one claim or incident, please photocopy and complete a separate form for each. Attach additional
sheets if necessary for adequate explanation. All questions must be answered or marked Not Applicable (N/A), and each
sheet must be signed.
Name of Patient:____________________________________________ Age:______ Sex:_______
Incident Claim
Date reported to insurance company: ______________
Name of insurance company: _______________________________________________
Date of incident and your treatment: __________________________________________________________
Allegations / Circumstances: ___________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Additional Defendants: _______________________________________________________________________
What is the present condition of the patient?______________________________________________________
___________________________________________________________________________________________
STATUS OF CLAIM
Suit threatened, no action taken Court outcome in YOUR favor: Unresolved/Open
Suit filed but dropped by claimant Jury verdict Awaiting mediation
Summary judgment in your favor Directed verdict Awaiting court action
Reserve amount:
$__________________
Suit settled out of court Court outcome in favor of plaintiff:
a. Date claim paid: _____________ Jury verdict
b. Amount paid: $_____________ Directed verdict
c. Did you want to settle? Amount of loss payment:
Yes No $_____________________
Name and address of the attorney assigned to your case: ____________________________________________
___________________________________________________________________________________________
To your knowledge, was any settlement paid by another party involved (i.e., your P.A., P.C., partners, employees, etc.)?
Yes: No:
Explain in detail what action(s) you have taken to prevent recurrence of this type of claim:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Signature: __________________________________ Date:_____________________
Printed Name: __________________________________
SUPPLEMENTAL CLAIM / INCIDENT INFORMATION
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AH MEDICAL LAB And IMAGING 1 (Kinsale Insurance)

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Completed 16 July 2020

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