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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
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 Applicant 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.
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