Fillable ALLIED HEALTHCARE PROFESSIONALS APPLICATION

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ALLIED HEALTHCARE PROFESSIONALS APPLICATION

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The ALLIED HEALTHCARE PROFESSIONALS APPLICATION form is 9 pages long and contains:

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  • 98 check-boxes
  • 233 other fields

Country of origin: US
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Page 1 of 9
Kinsale Insurance Company
P.O. Box 17008
Richmond, VA 23236
(804) 289-1300
www.kinsaleins.com
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.
ALLIED HEALTHCARE PROFESSIONALS APPLICATION
Provide a fully completed application, signed and dated by the applicant, 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 your Curriculum Vitae/Resume
- Copy of all licenses and board certifications
- Copy of your business letterhead, if you own your practice
- 5-year company loss runs, valued within the last 60 days
PERSONAL INFORMATION
Applicant’s Name and Degree designation(s): _____________________________________________________________
Social Security Number: ________ - ______ - ________ Date of Birth _____ / _____ / ________
Mailing Address: ___________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Practice Address: ___________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
E-Mail Address: ________________________________ Website Address: ___________________________________
SPECIFICS OF PRACTICE/PROCEDURES
1. Principal practice location for which coverage is requested:
_______________________________________________________________________________________________
(Practice Name) (Street)
_______________________________________________________________________________________________
(City) (State) (Zip)
a. Provide the number of weekly hours for your principal practice location (exclude on-call hours): _____________
Page 2 of 9
b. Your principal practice location is a(n):
Hospital Ambulatory Surgery Center Professional Office with Specialty Other _____________
2. Secondary practice location for which coverage is requested (If none, check here )
_______________________________________________________________________________________________
(Practice Name) (Street)
_______________________________________________________________________________________________
(City) (State) (Zip)
a. Provide the number of weekly hours for your secondary practice location (exclude on-call hours): ____________
b. Your principal practice location is a(n):
Hospital Ambulatory Surgery Center Professional Office with Specialty Other _____________
3. Please indicate your professional specialty: ___________________________________________________________
4. Do you render professional services directly to patients? ………………………………………………………………….
If yes, please describe these services in detail and indicate whether you are supervised and by whom.
YES NO
__________________________________________
Detailed Description of Professional Services
__________________________________________
__________________________________________
_________%
% Supervised
_________%
_________%
_____________________________________
Name of Supervising/Collaborating Physician
_____________________________________
_____________________________________
5. Do you render professional services that do not involve contact with a patient? ……………………………..
YES NO
If yes, please describe these services in detail ___________________________________________________________
________________________________________________________________________________________________
6. Do you perform or assist in any surgical procedures?............................................................................
If yes, please answer (i) below.
YES NO
i. Please list all surgical procedures performed (including minor surgery): __________________________________
____________________________________________________________________________________________
ii. Is anesthesia (other than topical or by means of local infiltration) administered by either
yourself or others? If yes, please attach a detailed explanation.
YES NO
iii.
Do you perform or assist in any surgical procedure(s) in a professional office or similar
non-hospital facility? If yes, please attach a detailed explanation
YES NO
7. Do you perform radiation therapy?.……………………………………………………………………………………………………
YES NO
8. Do you perform psychiatric shock therapy?............................................................................................
YES NO
9. Do you prescribe or dispense any drugs without the countersignature of a physician?
If yes, please provide a detailed explanation below.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Page 3 of 9
10. Please indicate the approximate percentages of your patients for which coverage is requested:
_____% Hemodialysis
_____% Holistic Medicine
_____% Surgical
_____% Stress Testing
_____% Communicable
_____% Family Planning
_____% Psychiatric
_____% Substance Abuse
_____% Obstetrical
_____% Gynecology
_____% Dental
_____% Family/General Practice
_____% Pediatric
_____% Bariatrics
_____% Physical Rehabilitation
_____% Disability Evaluation
_____% Research or Experimental
_____% Other _______________________
11.
Please give the approximate percentages of time spent in the following work locations:
_____% Administrative Office
_____% Ambulance
_____% Classroom
_____% Emergency Dept. of Hospital
_____% Nursing Home
_____% Laboratory
_____% Operating Room
_____% Outpatient Clinic
_____% Patient’s Home
_____% Hospital Ward
_____% Professional Office
_____% Other _____________________
12.
Provide the following: Weekly
a. Average number of patients you saw during the last 12 months for all jobs
Annually
b. Estimated number of patients you will see during the next 12 months for all jobs
c. Estimated number of patients you will see during the next 12 months for all jobs
for which coverage is requested
__________
__________
__________
__________
__________
__________
13. If you are the owner of the practice, indicate your sources and amounts of actual and projected total revenue:
Charitable Contributions:
Source
Government Funding:
Fee for Services:
Other: ______________________
$ __________________
Amount This Fiscal Year
$ ___________________
$ ___________________
$ ___________________
$ ___________________
Amount Next Fiscal Year
$ ___________________
$ ___________________
$ ___________________
PRACTICE SPECIALTY AND EDUCATION
14. Provide the following information for all of the states in which you practice:
_________________
State
_________________
_________________
__________________
License #
__________________
__________________
__________________
__________________
__________________
Effective Date
__________________
__________________
_________________
Expiration Date
__________________
__________________
__________________
Active (Yes/No)
15. Describe your professional training:
Name of Institution Years of Training
_________________________________ From ________ To ________ ________________________
Degree or Certification Attained
_________________________________ From _________ To ________ ________________________
_________________________________ From _________ To ________ ________________________
16. Is the Applicant a “Covered Entity” under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Privacy? If yes,
a. Has the Applicant implemented procedures to comply with the HIPPA Privacy Rule? YES NO
Page 4 of 9
b. Provide the name and title of the Applicant’s Privacy Officer: ___________________________________
17. Are you a member of any professional societies? If yes, list memberships below YES NO
_______________________________________________________________________________________________
18. List all locations and dates where you have practiced in the last 10 years:
Practice Name City/State From To
PRACTICE INFORMATION
19. Type of practice for which coverage is requested:
Solo practitioner (unincorporated)
Partnership
Professional Association
Employee of ______________________________
Solo practitioner (incorporated)*
* Name of Entity: _________________________________
Professional Corporation (for profit)
Professional Corporation (not for profit)
Other _________________________________________________________________________
20. Do you own or operate any business other than that shown above?
If yes, please give details on a separate sheet.
YES NO
21. Are you employed or contracted by any individual or entity other than your principal practice
location(s)?
If yes, please attach a description of your responsibilities.
YES NO
22. Are you employed by or under contract to any government entity?
If yes, please attach a description of your responsibilities.
YES NO
23.
Do you advertise your professional services in any manner (other than a simple listing in a
telephone directory)?
If yes, attach a copy of all of your advertisements.
YES NO
24.
Are you associated with any agency or organization that engages in any kind of advertising for, or
solicitation of, patients?
If yes, please attach a detailed explanation and copy of all advertisements.
YES NO
PRIOR POLICY AND LOSS INFORMATION – Questions 25-40 provide details for all “YES” answers
25.
Has your medical or narcotics license ever been limited, suspended, revoked, denied, or
investigated by any licensing board or regulatory agency?
YES NO
26.
Has your board certification or membership in any medical society or association ever been
refused, suspended, revoked, or voluntarily surrendered?
YES NO
27.
Have your hospital privileges ever been suspended, restricted, denied, placed in probationary
status, or revoked?
YES NO
YES NO
29.
Have you ever been diagnosed or treated for alcoholism, drug addiction, any chemical
dependency, or mental or chronic physical illness?
YES NO
30.
Has any fee or professional relations complaints been registered against you with your medical
association, hospital, or a state licensing authority?
YES NO
Page 5 of 9
REQUESTED COVERAGE
(NOTE: The Company may not offer or quote requested coverage)
Requested Effective Date:____________
Requested Retroactive Date:_______________
Requested Limits of Liability
___ $100,000/$300,000 ___ $200,000/$600,000
___ $250,000/$750,000
___ $500,000/$1,500,000 ___ $1,000,000/$3,000,000
___ $2,000,000/ $6,000,000 (VA only)
31. Provide the following information pertaining to your past 5 years of professional liability insurance coverage:
Carrier Policy Period Policy Limits Deductible
Claims Made? (Y/N)
Retro Date
32.
Do you currently participate in or plan to participate in a state patient compensation fund, health
care stabilization fund or other governmentally established malpractice liability funding
mechanism? If yes, identify __________________________________________________________
YES NO
33.
Have you ever practiced without professional liability insurance? YES NO
If yes, please explain on page 6
YES NO
liability insurance policy?
YES NO
YES NO
37.
Are you aware of any known losses or claims that have not been reported to a prior insurance
carrier or any other source from which payment might be made?
YES NO
result in a claim?
YES NO
39. Are you aware of any prior professional liability carrier refusing coverage for, or declining to accept
a report of a specific act, omission, or circumstance involving particular and specific professional
services that may result in a claim, threat of claim, letter of intent, adverse result notice, or
attorney contact?
YES NO
without merit, been reported to your current or prior professional liability company? Indicate N/A
if you are not aware of any such circumstances. If yes, how many? ____ please complete a
supplemental claims form for each.
YES NO
N/A
Page 6 of 9
SUPPLEMENTAL INFORMATION
Use this page to as needed to address questions referenced within the application or to provide information
you deem pertinent to our review of your application
• I have
STATEMENT OF NO KNOWN CLAIMS or CIRCUMSTANCES
no known losses or claims
• I have
that have not been reported to my prior insurance carrier or any other source from
which payment might be made;
no knowledge
• I have
of acts, omissions or circumstances that relate to a professional service which could reasonably
result in a claim, that has not been reported to a prior insurance carrier;
no knowledge
• I have
of any request for medical records by a patient or their attorney which might result in a claim;
no knowledge
• I have
or information relating to service or services on a Board which might result in a claim; and
no knowledge
of any prior professional liability carrier refusing coverage for, or declining to accept a report of a
specific act, omission or circumstance involving particular and specific professional services that may result in a claim,
threat of claim, letter of intent, adverse result, or attorney contact.
My signature on page 8 below confirms the above statements unless otherwise noted
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
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.
FRAUD WARNING
Page 8 of 9
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
fact.
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: _________________________________
Applicants Signature: _____________________________________ Date: ______________________________
Agent/Broker Name: __________________________________________________________________________
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Page 9 of 9
CLMF FRAUD OR
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?______________________________________________________
___________________________________________________________________________________________
Suit threatened, no action taken Court outcome in YOUR favor: Unresolved/Open
STATUS OF CLAIM
Suit filed but dropped by claimant Jury verdict Awaiting mediation
Summary judgment in your favor Directed verdict Awaiting court action
Suit settled out of court Court outcome in favor of plaintiff: Reserve amount: $__________________
Date claim paid: _____________ Jury verdict
Amount paid: $_____________ Directed verdict
Did you want to settle? Yes No Amount of loss payment: $_____________________
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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ALLIED HEALTHCARE PROFESSIONALS APPLICATION

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Completed 2 July 2020

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