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APPLICATION FOR DENTISTS AND ORAL SURGEONS PROFESSIONAL LIABILITY (Risk Placement Services, Inc.)

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MM-30002-01 08/08 Page 1 of 9
APPLICATION FOR DENTISTS AND ORAL SURGEONS PROFESSIONAL LIABILITY INSURANCE
NOTICE: The policy for which application is made provides coverage on a “CLAIMS MADE” basis. Please read the policy
carefully.
If space is insufficient to answer any question fully, attach a separate sheet.
I. GENERAL INFORMATION
1. (a) (i) Full name of Applicant:
(ii) Professio
nal Degree:
(b) Princi
pal practice address:
(Street) (County)
(City) (State) (Zip)
(c) Secondary practice locations:
(d) (i)
Phone:
(ii) Fax:
(iii) E-Mail
Address:
(iv) Website Address:
(e)
(i) Date of Birth (
MM/DD/YYYY): (ii) Place of Birth:
2. Are you a U.S. c
itizen? ........................................................................................................................... [ ] Yes [ ] No
If No, what is your status in the U.S. and current citizenship?
3. (a)
Type of practice: [ ] solo practitioner (unincorporated) [ ] solo practitioner (incorporated)*
[ ] professional corporation* [ ] professional association*
[ ] limited liability company* [ ] partnership*
[ ] employee of
[ ] independent contractor of
[ ] other
* Specify name of entity:
(b) Do you want coverage for the entity named Item 3(a) above? ......................................................
[ ] Yes [ ] No
(c) Attach a copy of your letterhead.
(d) If you practice other than as an employee, unincorporated solo practitioner or independent contractor, list the
names of all others practicing under the entity name in Item 3(a)above.
4. Do you practi
ce with any dentist not named in Item 3.(d) above?.......................................................... [ ] Yes [ ] No
If Yes, provide the name of each dentist and the practice relationship.
5. Are you currently in active military servi
ce?............................................................................................ [ ] Yes [ ] No
MM-30002-01 08/08 Page 2 of 9
6. Provide the following information for all of the states in which you practice:
State
License No. Effective Date Expiration Date Active (Yes/No)
7. Fede
ral DEA License No. and status:
8. Provide the following information for all
hospitals and surgi-centers where you are currently on staff:
Name
City State Percentage of Work Type of Privileges
9. Are you c
urrently a hospital chief of staff or head of any hospital department?...................................... [ ] Yes [ ] No
If Yes, describe.
10. Do you or the
entity firm named in Item 3(a) above own (either wholly or in part), operate or
administer any hospital, nursing home, surgicenter, urgent care center other facility where medical
services are customarily provided? ......................................................................................................... [ ] Yes [ ] No
If Yes, provide a detailed explanation specifically including the name, location, size, and number of beds.
11. Is the Applica
nt a “Covered Entity” under the Health Insurance Portability and Accountability Act of
1996 (HIPAA) Privacy Rule?.................................................................................................................... [ ] Yes [ ] No
If Yes,
(i) Has the Applicant implemented procedures to comply with the HIPAA Privacy Rule?................... [ ] Yes [ ] No
(ii) Provide the name and title of the Applicant’s Privacy Officer.
Our Busin
ess Associate Agreement is available at www.markelcorp.com
. This is the only Business Associate
Agreement we will recognize.
II. EDUCATION AND TRAINING
1. (a) Provide your dental specialty:
(b) Do you limit your prac
tice to the specialty stated in item (a) above? .............................................. [ ] Yes [ ] No
If No, provide details.
2. Are you Americ
an dental board certified in any specialty?...................................................................... [ ] Yes [ ] No
If Yes, provide the following: Board(s) in which you are certified:
Date of certification:
Any recertification date(s):
If No, do you plan on taking a Board examination? ................................................................................ [ ] Yes [ ] No
3. Provide the following information: Date
Name of Institution
City State Completed
Dental School
Internship – Specialty:
Reside
ncy – Specialty:
Fellowship – Specialty:
Other:
4. If you graduat
ed from a foreign dental school, provide the date began your practice in the United States:
5. Provide a det
ailed summary of where you have practiced your profession since completing your training:
Street Address
City, State Country From (MM/YY) To (MM/YY)
MM-30002-01 08/08 Page 3 of 9
6. Indicate the professional organizations which you are a member of:
[ ] American Association of OMS (AAOMS) [ ] American Society of Dentist Anesthesiologists (ASDA)
[ ] American College of OMS ((ACOMS) [ ] State Society of OMS
[ ] American Dental Association [ ] OMS Society – Other
[ ] Other (describe)
7. Ho
w many hours of continuing dental or medical education have you taken within each of the last two (2) years?
III. SCOPE OF PRACTICE
1. Provide the approximate percentage of your practice in the following:
Bone Grafting
% Microneurosurgical Procedures %
Cosmetic Dentistry Oral Pathology
%
Bonding
% Oral Radiology %
Enamel Shaping
% Orthodontics %
Full Month Restoration – Cosmetic Only
% Orthognathic Procedures %
Veneers
% Pediatric Dentistry %
Whitening with lasers
% Periodontics %
Other Cosmetic Procedures (describe) Prosthodontics
%
% Prosthetics
Non-Dental Cosmetic Procedures (including Fixed
%
injecting Botox, collagen and fillers)(describe) Removable
%
% Sleep Apnea
Endodontics Surgery
%
Single Rooted
% Therapy %
Multi Rooted
% Surgery
Sargenti Root Canal Method
% Facial – Elective Cosmetic %
General Dentistry Head and Neck
%
Extractions of Impacted Teeth
% Oral/maxillofacial %
Oral Surgery (describe)
Outside oral/maxillofacial region
% (describe) %
Root Canal
% TMJ %
Simple Extractions Only
% Non-surgical %
Implants Surgery
%
Restoration
% Other (describe) %
Placement
TOTAL 100%
2. Have you performed any implant procedures during the last 12 months? ............................................. [ ] Yes [ ] No
If Yes, answer the following:
(a) Provide the number of procedures performed:
Osseointegration only
Endoste
al (surgically inserted into the jawbone)
Mandibular Multi-quadrant – Ramus Frame
Other
Subpe
riosteal (lie on top of jawbone but underneath gum tissue)
Transosseus (penetrate entire jaw and emerge opposite the entry site)
Other (describe)
(b) Do your d
ental records include written notes that a process of patient evaluation occurred prior to
treatment?........................................................................................................................................ [ ] Yes [ ] No
(c) Do you perform any surgical procedures, such as sinus lifts, in conjunction with the placement
of implants?...................................................................................................................................... [ ] Yes [ ] No
(d) Attach a copy of the informed consent forms and patient education materials that are given to patients prior to
treatment.
3. Do you render any services outside the scope of your state’s Dental Practice Act? .............................. [ ] Yes [ ] No
If Yes, describe.
4. Do you us
e written informed consent documents for all procedures?..................................................... [ ] Yes [ ] No
If Yes, attached a copy of all form that are used. If No, attach an explanation.
MM-30002-01 08/08 Page 4 of 9
5. Have you ever used a Proplast Viatek TMJ Implant in your practice? ................................................... [ ] Yes [ ] No
If Yes,
(a) Have all such implants been replaced?........................................................................................... [ ] Yes [ ] No
(b) What is the date of the last implant?
6. Do you wire jaws
closed for the purpose of weight loss? ........................................................................ [ ] Yes [ ] No
If Yes,
(a) Number performed in the last 12 months:
(b) Estimated number that will be performed in the coming year:
7. Ha
s the nature of your practice, the type of procedures you perform or your use of anesthesia
changed in the last 5 years?.................................................................................................................... [ ] Yes [ ] No
If Yes, provide details.
8. Do you have
a surgical suite?.................................................................................................................. [ ] Yes [ ] No
If Yes, is your surgical suite certified?...................................................................................................... [ ] Yes [ ] No
If Yes, provide the name of the certification body.
9. What pe
rcentage of your patients are under age 18?
%
10. Do you perform any hospital emergency room care?.............................................................................. [ ] Yes [ ] No
If Yes, is this solely a requirement for active admitting privileges? ......................................................... [ ] Yes [ ] No
If No, provide a detailed description including the approximate number of hours per month spent in emergency room
care.
11. Do you
perform consultations outside the state of your primary office address, including but not
limited to the use of telecommunications technology as the medium for rendering dental/medical
services, dental/medical opinions or dental/medical advice? .................................................................. [ ] Yes [ ] No
If Yes, provide the following:
(a) Identify all states in which such patients reside:
(b) What pe
rcentage of your total practice is involved in such activities?
12. Do you re
ad, interpret or diagnose films, slides or specimens taken from patients residing in states
other than your primary practice address? .............................................................................................. [ ] Yes [ ] No
If Yes, identify all states in which such patients reside.
13. (a)
Do you use experimental procedures, devices, drugs or therapy in treatment or surgery?............ [ ] Yes [ ] No
If Yes, do you follow FDA-approved protocols? ............................................................................. [ ] Yes [ ] No
If Yes, describe.
(b) Are you a Princ
ipal Investigator for any clinical trial? ...................................................................... [ ] Yes [ ] No
14. (a) Indicate the number of professional employees in your practice for each of the following:
(If none, check here [ ])
Dentists other than yourself Hygienists Surgeon’s Assistants* Nurses
Dental Assistants Physicians Nurse Anesthetists*
Dental Technicians Physicians Assistants* Laboratory/Radiology Technicians
Other (describe)
*Provide a description of duties, in detail, including extent supervised on a separate page and attach protocols.
(b) Are all of the above individuals licensed in accordance with applicable state and federal
regulations? .................................................................................................................................... [ ] Yes [ ] No
If No, provide a detailed explanation on a separate page.
15. (a) Average weekly patient load:
(b) Number of patients annually:
16. Average n
umber of hours you practice each week:
17. What is you
r approximate gross annual income from your practice? (Check one.)
Less than $50,000 $50,000 to $99,999
$100,000 to $149,999 $150,000 to $199,999
MM-30002-01 08/08 Page 5 of 9
$200,000 to $499,999 $500,000 or more (estimate) $
18. (a)
Do you supervise anyone other than your own employees?........................................................... [ ] Yes [ ] No
If Yes, indicate by profession the number of individuals you supervise:
Dentists other than yourself Hygienists Surgeon’s Assistants* Nurses
Dental Assistants Physicians Nurse Anesthetists*
Dental Technicians Physicians Assistants* Laboratory/Radiology Technicians
Other (describe)
* Attach protoc
ols and description of the extent in which you supervise such persons.
Provide a detailed explanation of the responsibilities for each profession and your relationship to the entity that
employs these individuals.
(b) Are all of th
e above individuals licensed in accordance with applicable state and federal
regulations? ..................................................................................................................................... [ ] Yes [ ] No
If No, provide a detailed explanation on a separate page.
19. If you perform any of the following procedures, check all that apply. For each procedure performed indicate where
the procedure is performed: H = Hospital O = Office S = Surgi-center or Certified Surgical Suite
Location
Acupuncture
Adenoidectomy/Tonsillectomy
Anesthes
ia:
General
Twilight
Other – (describe)
Assi
sting in Surgery:
Oral Surgery
Other Surgery (describe)
Biopsies (describe)
Blepharoplasty
Cheek Implant
Chemical Peel:
Solution Strength(specify)
Chin Surgery
Cleft Lip and Palate Surgery
Cosmetic implantation of
silicone or other material
Cosmetic Surgery
Cryosurgery
Dental Alveolar Surgery
Dermabrasion/Microdermabrasion
Extractions
:
Non-Impacted Teeth
Impacted Teeth
Face Lift
Location
Hair Transplants or Suturing of
Hairpieces
Laser Skin Resurfacing
Laser Surgery (describe)
Liposu
ction – above the neck
(specify volume)
Liposu
ction – below the neck:
under 3500 cc’s volume
3500 cc’s or more volume
Nerve Grafts
Oral/Maxillofacial Surgery
Open Reduction of Fractures
Pain Management (describe)
Plastic
Surgery:
Reconstructive Facial
Reconstructive - Other (describe)
Rhinoplasty
Radiation Therapy
Radiopaque dye injections into blood
vessels, lymphatics, sinus tracts or
fistulae
Sargenti Root Canal Method
Sinus Lift
TMJ Surgery
Uvulopalatoplasty
20. List your prior Professional Liab
ility Insurance for each of the last (5) years, including the current year:
(a) Limits of Claims Made or
Ins Company Liability Premium Eff./Exp. Dates Occurrence Form Retroactive Date
(1)
(2)
(3)
(4)
MM-30002-01 08/08 Page 6 of 9
(5)
(b) Doe
s the policy for the current year allow the reporting of any incidents or circumstances that
are likely to result in a claim?........................................................................................................... [ ] Yes [ ] No
(c) Do any of the above policies provide coverage for any:
(i) procedures not describes in this application and in which you no longer perform?................ [ ] Yes [ ] No
(ii) practice(s) not described in this application?........................................................................... [ ] Yes [ ] No
IV. ANESTHESIA INFORMATION
1. Is analgesia, sedation or anesthesia used on patients?.......................................................................... [ ] Yes [ ] No
If Yes, answer the following:
(a) Local only......................................................................................................................................... [ ] Yes [ ] No
(b) Inhalation conscious sedation.......................................................................................................... [ ] Yes [ ] No
If Yes, answer the following:
(i) Percentage of patients under age 18:
%
(ii) Drugs used: [ ] Nitrous Oxide [ ] Other
(iii) Is sed
ation done in an office, surgi-center or hospital?
(iv) Administe
red by: [ ] You [ ] Oral Surgeon [ ] Physician Anesthesiologist
[ ] Dentist Anesthesiologist [ ] CRNA [ ] RN/LPN [ ] Other:
(c) Oral
conscious sedation using drugs that are swallowed ............................................................... [ ] Yes [ ] No
If Yes, answer the following:
(i) Percentage of patients under age 18:
%
(ii) List all drugs used:
(iii) Is sed
ation done in an office, surgi-center or hospital?
(iv) Ho
w long have you used conscious sedation in your office or surgical suite?
(v) Administe
red by: [ ] You [ ] Oral Surgeon [ ] Physician Anesthesiologist
[ ] Dentist Anesthesiologist [ ] CRNA [ ] RN/LPN [ ] Other:
(d) Parente
ral conscious sedation (minimally depressed level of consciousness that retains the
patient’s ability to independently and continuously maintain an airway and respond appropriately
to physical stimulation and verbal command, produced by a pharmacological or non-
pharmacological method, or a combination thereof) ....................................................................... [ ] Yes [ ] No
If Yes, answer the following:
(i) Percentage of patients under age 18:
%
(ii) List all drugs used:
(iii) Is sed
ation done in an office, surgi-center or hospital?
(iv) Ho
w long have you used conscious sedation in your office or surgical suite?
(v) Administe
red by: [ ] You [ ] Oral Surgeon [ ] Physician Anesthesiologist
[ ] Dentist Anesthesiologist [ ] CRNA [ ] Other:
(e) Parenteral de
ep sedation (a controlled state of depressed consciousness accompanied by
partial loss of protective reflexes, including inability to respond purposely to verbal command,
produced by a pharmacological or non-pharmacological method, or a combination thereof) ........ [ ] Yes [ ] No
If Yes, answer the following:
(i) Percentage of patients under age 18:
%
(ii) List all drugs used:
(iii) Is sed
ation done in an office, surgi-center or hospital?
(iv) Administe
red by: [ ] You [ ] Oral Surgeon [ ] Physician Anesthesiologists
[ ] Dentist Anesthesiologist [ ] CRNA [ ] Other:
MM-30002-01 08/08 Page 7 of 9
(f) General anesthesia (a controlled state of unconsciousness accompanied by partial or complete
loss of protective reflexes, including inability to independently maintain an airway and respond
purposefully to verbal command, produced by a pharmacological or non-pharmacological
method, or a combination thereof)................................................................................................... [ ] Yes [ ] No
If Yes, answer the following:
(i) Percentage of patients under age 18:
%
(ii) List all drugs used:
(iii) Is sed
ation done in an office, surgi-center or hospital?
(iv) Ho
w long have you used general anesthesia in your office or surgical suite?
(v) Administe
red by: [ ] You [ ] Oral Surgeon [ ] Physician Anesthesiologist
[ ] Dentist Anesthesiologist [ ] CRNA [ ] Other:
(g) Are Harvard Standards for the administ
ration of all anesthesia adhered to?.................................. [ ] Yes [ ] No
If No, explain.
2. (a)
Have you completed an ACLS course?........................................................................................... [ ] Yes [ ] No
(b) Do you hold an ACLS certificate?.................................................................................................... [ ] Yes [ ] No
If Yes, what it’s the expiration date?
If No, are you c
urrently CPR Certified? ........................................................................................... [ ] Yes [ ] No
(c) Is any member of your operating staff currently CPR certified?...................................................... [ ] Yes [ ] No
3. Check all that apply:
(a) Have you completed an ADA-accredited general anesthesia program of one year or longer? ...... [ ] Yes [ ] No
(b) Did your oral surgery training include 6 or more months of training in general anesthesia? .......... [ ] Yes [ ] No
(c) Have you taken at least two years of anesthesia training following dental school for certification
as an anesthesiologists? ................................................................................................................. [ ] Yes [ ] No
4. Are vital signs of your patients under sedation or general anesthesia continuously monitored?............ [ ] Yes [ ] No
If Yes, by whom? [ ] You [ ] CRNA [ ] Dentist Anesthesiologist [ ] Other:
5. If
you use any of the following methods to monitor patients, indicate by using S for sedation, G for general anesthesia or
B for both.
Manual monitoring of blood pressure and heart rate
___ Precordial stethoscope
___ Electronic/automatic monitoring of blood pressure and heart rate
___ EKG monitor
___ Pulse oximeter
___ Other (describe)
6. Which of the
following items do you have available for emergency treatment? Check all that apply.
___ Oral airway ___ Ambu bag
Endotracheal tubes/scopes
___ Oxygen ___ Emergency drugs
7. Does the state you practice in require you to hold a current certificate/permit to administer general
anesthesia or intravenous sedation? ........................................................................................................ [ ] Yes [ ] No
If Yes, provide the following:
Certificate number:
Date of renewal:
V. AFFILIATIONS
1. Are you in the employ of any individual, firm or corporation other than the employer named in
Section I. 3(a) above?.............................................................................................................................. [ ] Yes [ ] No
If Yes, provide a detailed explanation including a description of your responsibilities.
2. Are you unde
r contract to any individual, firm or corporation other than the contracting entity named
in Section I. 3(a) above? .......................................................................................................................... [ ] Yes [ ] No
If Yes, provide a detailed explanation including a description of your responsibilities.
MM-30002-01 08/08 Page 8 of 9
If Yes, does any contract contain a hold harmless agreement?.............................................................. [ ] Yes [ ] No
If Yes, attach a copy of the contract.
3. Are you in the employ of or under contract to any governmental entity? ................................................ [ ] Yes [ ] No
If Yes, provide a detailed explanation including a description of your responsibilities.
4. Do you adve
rtise your professional services in any manner other than a simple listing in a telephone
directory? ................................................................................................................................................ [ ] Yes [ ] No
If Yes, attach a copy of all advertisements.
5. Are you associated with any agency or organization that engages in advertising for, or solicitation of
patients?................................................................................................................................................... [ ] Yes [ ] No
If Yes, attach a copy of the advertisement or applicable website address.
6. Are you the Dental/Medical Director of a nursing home, clinic, commercial enterprise or any other
organization?............................................................................................................................................ [ ] Yes [ ] No
If Yes, provide a detailed explanation and attach a copy of any contract or other agreement that describes your
position.
7. Do you have
any administrative or teaching responsibilities?................................................................. [ ] Yes [ ] No
If Yes, provide the following and attach a copy of any contract or agreement:
(a) Name of entity and location:
Your title
(b) Doe
s the entity provide you coverage for:
(i) Your administrative responsibilities? ....................................................................................... [ ] Yes [ ] No
(ii) Your direct patient care? ......................................................................................................... [ ] Yes [ ] No
8. Do you work for any locum tenens companies?...................................................................................... [ ] Yes [ ] No
If Yes, attach a copy of your Certificates of Insurance.
9. Do you provide any services to any adult or juvenile inmates in any local, state or federal
correctional facility, jail, prison, holding facility or other location? .......................................................... [ ] Yes [ ] No
If Yes, provide details.
10. Are you engaged in or pl
anning to engage in any “moonlighting” activities? .......................................... [ ] Yes [ ] No
If Yes, do you want coverage for your “moonlighting” activities? ............................................................ [ ] Yes [ ] No
If Yes, describe the activities.
VI. CLAIMS AND HISTORY
1. Has any claim or suit for malpractice ever been made against you or any entity proposed for this
insurance?............................................................................................................................................... [ ] Yes [ ] No
If Yes, how many?
Complete a copy of our Supplemental Claim form for each one.
2. Has any claim or suit for malpractice ever been made against you or any entity proposed for this
insurance that has not been reported to the current insurer or any prior insurer? ................................. [ ] Yes [ ] No
If Yes, how many?
Complete a copy of our Supplemental Claim form for each one.
3. Are you or any entity 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?... [ ] Yes [ ] No
If Yes, how many?
Complete a copy of our Supplemental Claim form for each one.
4. Have you ever been investigated, asked to resign or been involved in official or non-official
proceedings brought by a hospital, managed care organization or other healthcare organization to
deny, limit, suspend, non-renew or revoke your privileges?.................................................................... [ ] Yes [ ] No
5. Has your license to practice dentistry or your permit to prescribe or dispense drugs ever been
limited, suspended, revoked, placed on probation or been voluntarily surrendered in any state?.......... [ ] Yes [ ] No
6. Have you ever been notified to respond to, appear before or have you ever been investigated by
any licensing or regulatory agency on a complaint of any nature, including but not limited to
unprofessional or unethical conduct? ...................................................................................................... [ ] Yes [ ] No
7. Have you ever been charged with or convicted of an act committed in violation of any law or ordinance?
................................................................................................................................................................. [ ] Yes [ ] No
MM-30002-01 08/08 Page 9 of 9
8. Have you ever been evaluated, treated or hospitalized for alcohol or substance abuse or mental or
emotional disorders?................................................................................................................................ [ ] Yes [ ] No
9. Have you ever had or do you now have a physical or mental disability or other condition or
circumstance that, despite reasonable accommodation, would limit your ability to safely practice in
your medical specialty?............................................................................................................................ [ ] Yes [ ] No
Note: If the Applicant does not purchase prior acts coverage from the Company there will be no coverage with
the Company for any claim, suit or circumstance based upon the rendering or failure to render
professional services prior to the effective date of the Applicant’s policy, if issued.
NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY
The policy applied for is SOLELY AS STATED IN THE POLICY, if issued, which provides coverage on a "CLAIMS MADE"
basis for ONLY THOSE “CLAIMS” THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD,
unless the Optional Extension Period option is exercised in accordance with the terms of the policy.
The underwriting manager, Company and/or affiliates thereof is authorized to make any inquiry in connection with this
application. Signing this application does not bind the Company to provide or the Applicant to purchase the insurance.
This application, information submitted with this application and all previous applications and material changes thereto of
which the underwriting manager, Company and/or affiliates thereof receives notice is on file with the underwriting
manager, Company and/or affiliates thereof and is considered physically attached to and part of the of the policy if
issued. The underwriting manager, Company and/or affiliates thereof will have relied upon this application and all such
attachments in issuing the policy. If the information in this application or any attachment materially changes between the
date this application is signed and the effective date of the policy, the Applicant will promptly notify the underwriting
manager, Company and/or affiliates thereof, who may modify or withdraw any outstanding quotation or agreement to bind
coverage.
WARRANTY
I warrant to the Company, that I understand and accept the notice stated above and that the information contained herein
is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company evidence its
acceptance of this application by issuance of a policy. I authorize the release of claim information from any prior insurer to
the underwriting manager, Company and/or affiliates thereof.
Must be signed by the Applicant within 60 days of the proposed effective date.
Name of Applicant Title
Signature of Applican
t Date
Notice to Applicants: 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 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.
ADDITIONAL EXPLANATIONS
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APPLICATION FOR DENTISTS AND ORAL SURGEONS PROFESSIONAL LIABILITY (Risk Placement Services, Inc.)

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Completed 30 July 2020

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