Fillable AH SURGERY CENTER 1 (Kinsale Insurance)

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AH SURGERY CENTER 1 (Kinsale Insurance)

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  • 276 check-boxes
  • 290 other fields

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Page 1 of 11
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 (supplement required):
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 (supplement required):
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 - AMBULATORY SURGERY CENTER APPLICATION
Page 2 of 11
AMBULATORY SURGERY CENTER APPLICATION
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
8. Date Established _____________________ Years under current management _____________
9. Applicant is a:
Individual
Professional Associations
Corporation
Partnership
LLC
Joint Venture
Other:____________________________________
1. Full name of Applicant (Including DBA’s) _______________________________________________________________
2. Mailing Address:_____________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
3. Location Address(es): 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:
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 3 of 11
10. Enterprise is: For Profit Not For Profit
11. Is this entity owned by, associated with or controlled by any other entity? Yes No
If yes, please provide details:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
11. What are the facility days and hours of operation?
12. Is the applicant accredited by or a member of any professional organization or association? Yes No
If yes, please name:
13. Estimated annual gross revenues in the next 12 months? $__________________
Annual gross revenues in the past 12 months? $__________________
14. Does applicant maintain beds for overnight occupancy? Yes No
If yes, how many? __________ Also attach a copy of license and an explanation including protocols for onsite 24
hour staffing.
15. Please provide number of procedures for the following:
TYPE OF PROCEDURE
NUMBER PAST 12 MONTHS
ESTIMATED NUMBER NEXT
12 MONTHS
Abortions
Bariatric Surgery
Cosmetic Surgery
Dental/ Oral Surgery
Endoscopy/ Colonoscopy
General Surgery
Gynecological Surgery
Manipulation under Anesthesia
Obstetric
Ophthalmology - Cataract
Ophthalmology – Lasik / Refractive
Orthopedic Surgery
Orthopedic Surgery – Including Spine
Otorhinolaryngology with Plastic
Otorhinolaryngology no Plastic
Pain Management
Plastic/ Reconstructive Surgery
Podiatry
APPLICANT’S PRACTICE
Page 4 of 11
Radiological/ Nuclear/ Chemotherapy
Other: (describe)
Other: (describe)
16. Any other services (other than surgery) not listed above? (i.e. Lab, Imaging, Office Visits, etc.) Yes No
If yes, please list type and amount.
_______________________ __________________
_______________________ __________________
_______________________ __________________
_______________________ __________________
17. IF ABORTIONS are indicated please complete the following otherwise skip to question 18.
0-13 Weeks
Gestation
13-16 Weeks
Gestation
16-20 Weeks
Gestation
20+ Weeks
Gestation
Total
# of Surgical
Abortions
# of Medical
Abortions
a. Does the applicant perform ultrasounds prior to any abortions? Yes No
b. Please specify method(s) used for both Medical and Surgical Abortions:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
18. IF BARIATRIC SURGERY is indicated please complete the following otherwise skip to question 19.
a. Please list all procedures and attach protocols for selecting and monitoring patients.
_______________________________________________________________________________
_______________________________________________________________________________
b. Is Bariatric surgery only performed by American Board Certified General Surgeons? If no, on a separate page
please describe which other surgical specialists are performing this procedure and the reasons why they
have been granted privileges to perform this procedure ..…………………………………………………….
Yes No
c. Is this center a Bariatric Surgery Center of Excellence? ............................................................. Yes No
19. IF PLASTIC OR COSMETIC SURGERY is indicated please list all cosmetic procedures performed including botox or
other injectables otherwise skip to question 20.
a. If liposuction (any form or type) is indicated as being performed is it only performed by an American Board
Certified Plastic Surgeon or General Surgeon? If no, on a separate page please describe which other surgical
specialists are performing this procedure and the reasons why they have been granted privileges to perform
this procedure.
........................................................................................................................Yes No
20. IF PAIN MANAGEMENT is indicated please list all Pain Management procedures performed otherwise skip to
question 21.
Page 5 of 11
21. Policies and Procedures – Pre-operative:
Are written consent forms used for each type of procedure performed? If yes, Is the
surgeon also required to sign the consent form?
Yes No
Yes No
Is the physician required to discuss the procedure and consent with the patient prior to
performing the procedure?
Yes No
Is there written documentation of a pre-operative anesthesia evaluation and airway
assessment per ASA guidelines?
Yes No
Preoperative history and physical examination in the medical record by the day of
surgery?
Yes No
Is there a formal process in place which includes pre-operative verification of the
patient?
Yes No
Is there a formal process in place which includes pre-operative verification of the
surgical site?
Yes No
Is there a formal process in place to which includes marking of the operative site?
Yes No
Is there a “time out” immediately before starting the procedure?
Yes No
22. Policies and Procedures – Intra and post-operative:
Is there documentation and signing of all intra-operative orders?
Yes No
Is there written documentation of all medications and intravenous fluids given?
Yes No
Are written post-operative instructions provided to all patients?
Yes No
Is there documentation and signing of all post-operative orders and timely dictation of
operative notes?
Yes No
Is there a formal discharge policy requiring that a patient meet specific criteria prior to
being discharged?
Yes No
23. Does the applicant have a preventative maintenance program for all biomedical equipment including anesthesia and
critical emergency equipment that includes:
a. Proper training of all equipment users? Yes No
b. Repairs by qualified personnel? Yes No
c. Documentation of all activities (preventive maintenance, repairs, education)? Yes No
24. Anesthesia Delivery and Monitoring:
a. What is the level of anesthesia provided?
Level A – Local or topical anesthesia
Level B – Local or topical anesthesia and/or IV or parenteral sedation, regional anesthesia, analgesia or
dissociative drugs without the use of endotracheal or laryngeal mask intubation or inhalation general
anesthesia
Level C – Levels listed above plus and/or surgical procedures with epidural anesthesia, endotracheal or
laryngeal mask intubation or inhalation anesthesia, spinal or epidural
b. Does the applicant permit professionals other than licensed Nurse Anesthetists and Anesthesiologists to
administer and/or monitor sedation or general anesthesia? Yes
No
c. Are non-Anesthesiologists administering Propofol or deep sedation? Yes No
25. Is there a documented protocol for handling in house emergencies? Yes No
26. Is there an agreement with a local hospital for emergency transfers? Yes No
POLICIES AND PROCEDURES
Page 6 of 11
27. What is the distance from the applicant to the nearest acute care hospital?
28. Please provide the name and specialty of the applicant’s Medical Director
______________________________________________________________________________________________
29. Does the applicant’s Medical Director have direct patient care? Yes No
30. Is the applicant’s Medical Director full-time or part-time?
31. Please complete the staff / credentialed provider table below AND provide a staff listing by name for all
credentialed physicians:
Number
Employed?
Number Privileged
Insured
Elsewhere?
Coverage
Desired?
Full
Time
Part
Time
Full Time
Part Time
Physicians: no surgery other than incision of boils
and superficial abscesses; suturing of skin or
superficial fascia
YES NO YES NO
Anesthesiologists; Pain Management Specialists
YES NO
YES NO
Dermatologist; Cardiologists; Gastroenterologist;
Proctologists; Ophthalmologists; Urologists,
Internists;
YES NO YES NO
General Surgeons; Cardiac Surgeons;
YES NO
YES NO
Obstetrics-Gynecologists, Plastic Surgeons, and
Otolaryngologists doing plastic surgery
YES NO YES NO
Thoracic Surgeons; Vascular Surgeons;
Neurosurgeons; and Orthopedic Surgeons
YES NO YES NO
Bariatric Surgeons
YES NO
YES NO
Podiatrists
YES NO
YES NO
Dentists; Oral Surgeons
YES NO
YES NO
Nurse Anesthetists
YES NO
YES NO
Physicians’ and Surgeons’ Assistants; Nurse
Practitioners
YES NO YES NO
Perfusionists
YES NO
YES NO
Pharmacists
YES NO
YES NO
Chiropractors
YES NO
YES NO
RNs, LPNs
YES NO
YES NO
X-Ray Technician; Lab Technician
YES NO
YES NO
Other (specify):
STAFF / CREDENTIALED PROVIDERS
Page 7 of 11
32. Are all above individuals licensed in accordance with applicable state and federal regulations?
Yes No
33. Do you require all employed, contracted, or privileged physicians or nurse anesthetists to carry
their own professional liability insurance? If yes, what limits are they required to carry?
________________________
Yes No
34. Does the Applicant have a formal credentialing and privileging process which includes primary
source verification of professional credentials and privilege qualifications for all surgeons and
anesthesia providers?
If yes, does it include the following AND attach copy of written credentialing protocols:
a. Review/approval of requested privileges by the center’s medical director and/or
credentials committee? Yes
No
b. Continuous updates of new or deleted privileges for ambulatory surgery center staff
either through an automated or manual system? Yes
No
Yes No
35. Can the Applicant’s staff refuse to schedule a surgery or procedure that is not:
a. On an individual provider’s list of approved privileges? Yes No
b.
Authorized at the Applicant’s surgical center? Yes No
Building Description
Buildings/Wings
#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
36. 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
37. Has any claim for General Liability ever been made against any person(s) or entity(ies) proposed
for this insurance? If Yes, answer complete a supplemental claims form for each.
YES NO
38. 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
PREMISES INFORMATION – complete only if you are requesting General Liability Coverage
Page 8 of 11
39. 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
40. 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? _____________
41. 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? Explain on page 9 or attach additional pages as needed
YES NO
42. Has the applicant or any of its employees ever been charged with, or convicted of a crime other than
minor traffic violations? Explain on page 9 or attach additional pages as needed
YES NO
43. 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? Explain on page 9 or attach additional
pages as needed
YES NO
44. 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
45. 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
46. 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
COVERAGE HISTORY
CLAIMS AND HISTORY – Please explain or complete a supplemental claim for form for all “Yes” answers
Page 9 of 11
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
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.
FRAUD WARNING
SUPPLEMENTAL INFORMATION (reference question number if applicable)
Page 10 of 11
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:
Page 11 of 11
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 SURGERY CENTER 1 (Kinsale Insurance)

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Completed 16 July 2020

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