Fillable AH SURGERY CENTER Renewal 1 (Kinsale Insurance)

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AH SURGERY CENTER Renewal 1 (Kinsale Insurance)

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  • 101 check-boxes
  • 167 other fields

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Page 1 of 6
AMBULATORY SURGERY CENTER RENEWAL 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 expiring effective date of coverage.
• If a question is not applicable, then state “N/A”.
4. Provide any other general information change(s) below:
___________________________________________________________________________________________
___________________________________________________________________________________________
7. Is the applicant accredited by or a member of any professional organization or association? Yes No
If yes, please name:
8. Estimated annual gross revenues in the next 12 months? $__________________
Annual gross revenues in the past 12 months?
$__________________
1. Full name of Applicant (Including DBA’s) _______________________________________________________________
2. Indicate change(s) in general information below. Check here if NO change(s) in general information from last year:
3. Mailing / Location Address(es):
(1) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(2) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Attach Additional Pages as Needed
5. Inspection/Risk Management Contact Name:
6. Inspection/Risk Management Contact E-mail:
GENERAL INFORMATION
APPLICANT’S PRACTICE
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
9. 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.
10. Please provide number of procedures / services for the following:
TYPE OF PROCEDURE
NUMBER PAST 12 MONTHS
ESTIMATED NUMBER NEXT
12 MONTHS
Abortions
Bariatric Surgery - List Procedures Below
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 – List Procedures Below
Plastic/ Reconstructive Surgery
Podiatry
Radiological/ Nuclear/ Chemotherapy
Other: (describe)
Other: (describe)
Other: (describe)
11. IF BARIATRIC SURGERY OR PAIN MANAGEMENT is indicated please complete the following
a. Please list ALL bariatric or pain management 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 N/A
c. Is this center a Bariatric Surgery Center of Excellence? Yes No N/A
Page 3 of 6
12. Please complete the staff / credentialed provider table below AND provide a staff listing by name for all
credentialed physicians.
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 4 of 6
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.
21. 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
22. 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 below or attach
additional pages as needed
YES NO
23. Has the applicant or any of its employees ever been charged with, or convicted of a crime
other than minor traffic violations? Explain below or attach additional pages as needed
YES NO
24. 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
below or attach additional pages as needed
YES NO
25. 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
FRAUD WARNING
CLAIMS AND HISTORY – Please explain or complete a supplemental claim for form for all “Yes” answers
SUPPLEMENTAL INFORMATION (reference question number if applicable)
Page 5 of 6
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 6 of 6
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 Renewal 1 (Kinsale Insurance)

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Completed 16 July 2020

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