Fillable Application - Medical Professional36-9341

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Application - Medical Professional36-9341

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MEDICAL PROFESSIONAL APPLICATION
NOTICE TO APPLICANT: THE COVERAGE FOR WHICH THE APPLICANT IS REQUESTING WILL APPLY ONLY TO CLAIMS
ARISING WHILE IN THE COURSE OF THEIR EMPLOYMENT FOR THE NAMED INSURED.
SECTION I – GENERAL INFORMATION
Applicant’s Last Name: First Name: M.I.
Date of Birth:
Current Medical License State(s):
Current Medical License Number(s):
SECTION II – EDUCATION AND TRAINING
1. Name and location of Medical / Dental School Granting Degree:
City State: Year graduated:
If Applicant is a graduate of a non-US medical school, have they obtained an ECFMG Certificate? Yes No
2. Independent memberships and professional societies:
3. Yes No
Medical Specialty
Date Certified
Medical Specialty
Date Certified
SECTION III – PROFESSIONAL SERVICES PROVIDED
1.
Type of Practice / Services:
Addiction Medicine
Geriatrics
Psychiatry
Dentist
Internal Medicine
Surgery
Family Medicine
Medical Director
Other:
Alternative / Unconventional Medicine (not mainstream), if applicable, please describe:
2.
Status:
Employed
Contracted
Volunteer
3.
Hours of Practice on behalf of the Applicant’s Employer or Named Insured:
FULL TIME
( > 20 hours per week) Professional Services rendered on behalf of Applicant’s Employer or
Named Insured.
PART TIME
( < 20 hours per week) Professional Services rendered on behalf of Applicant’s Employer or
Named Insured.
Please specify the exact # of hours rendered on behalf of the Applicant’s Employer or Named Insured: #
hours
4.
Does the Applicant’s practice include telemedicine activities, e.g., the transfer of data through
electronic (video or computer) means in order to provide healthcare to patients who are
geographically separated from the clinicians involved?
Yes
No
a.
If yes, what is the percent of the Applicant’s total practice time devoted to this activity? %
b.
If yes, on a separate sheet, please explain the exact type of telemedicine.
c.
Is telemedicine done outside the U.S. territories?
Yes
No
5. Does the Applicant obtain an informed consent, whether signed by patient or guardian before
prescribing controlled substances?
Yes
No
6.
Does the Applicant create and maintain medical records for each patient under their care?
Yes
No
If no, explain:
7. Does the Applicant participate in a compensation fund or other similar program of state sponsored
liability insurance? (Example: MCARE in Pennsylvania)
Yes
No
Physicians and Dentists Questionnaire
Page 1 of 4
© 2015 Philadelphia Consolidated Holding Corp.
02/2015
Is Applicant American Board Certified?
Print Application
Clear Application
SECTION IV – INSURANCE AND PROFESSIONAL HISTORY
1.
Has the Applicant ever been denied professional liability insurance coverage?
Yes
No
NOTE: MISSOURI APPLICANTS DO NOT RESPOND
If yes, please attach a separate sheet containing a complete explanation.
2.
Has the Applicant’s professional liability insurance coverage ever been cancelled or refused
renewal?
Yes
No
NOTE: MISSOURI APPLICANTS DO NOT RESPOND
If yes, please attach a separate sheet containing a complete explanation.
3. Has the Applicant’s application (new or renewal) for professional liability insurance coverage ever
been accepted subject to any conditions or restrictions?
Yes
No
If yes, please attach a separate sheet containing a complete explanation.
4.
Has the Applicant’s license ever been suspended or revoked?
Yes
No
If yes, please attach a separate sheet containing a complete explanation.
5.
Has the Applicant ever been convicted of a crime?
Yes
No
If yes, please attach a separate sheet containing a complete explanation.
SECTION V – PRIOR INSURANCE
List Applicant’s insurers or Applicant’s employers’ insurers the past (3) years. Attach additional pages as needed.
Insurance Carrier Policy Period Limits of Liability
Coverage Type
(Occurrence / Claims Made)
SECTION VI – PRACTICE LOCATIONS
Current Practice location on behalf of the Applicant’s Employer or Named Insured:
Insured’s Practice Location Address
From
(MM/YY)
To
(MM/YY)
SECTION VII - CLAIMS HISTORY
IMPORTANT: This section must be completed in its entirety. Any malpractice claims or suits in which Applicant has been
involved in during the past seven (7) years must be reported. Any incidents or circumstances of which the Applicant is
aware of that are likely to give rise to a claim must be reported. Provide copies of suit papers or claimant letters. If the
claim is closed, provide copies of settlement or judgment documents or order of dismissal. If reporting more than one
incident, suit or claim, photocopy this form for each.
N/A (Please proceed to signature section)
1.
Has the Applicant ever had any malpractice claim(s) or suit(s) brought against them?
Yes
No
If yes, please provide copies of suit papers or claimant letters. If the claim is closed, provide copies
of settlement or judgment documents or order of dismissal.
2.
Is the Applicant aware of any circumstances, which may result in a malpractice claim or suit?
Yes
No
If yes, please provide the details below:
a.
Name of patient:
b.
Allegation/incident description:
c.
Incident date:
Report date:
If reporting more than one incident, photo copy this form for each.
Physicians and Dentists Questionnaire
Page 2 of 4
© 2015 Philadelphia Consolidated Holding Corp.
02/2015
Clear Application
Print Application
SECTION VIII – CLAIMS MADE COVERAGE
Notice: This section is being completed as an application for a Claims-Made policy. Only claims which are first
made against the Applicant and reported to us during the policy period or Extended Reporting Period will be
covered, subject to policy provisions. Various provisions in the policy restrict coverage. Read the entire policy
carefully to determine the Applicant’s rights, duties and what is and is not covered.
Additional Notice: If Claims Made coverage is provided, it should be clearly understood that the applicable retro
date will be the latter of the medical professional’s date of hire or the date that the medical professional coverage
is added to the Named Insured’s policy.
N/A (Please proceed to signature section)
Policy Effective Date:
Line of Business:
1.
Within the past 5 (five) years has the Applicant given written notice under the provisions of any
current or prior policy providing similar insurance of any claim or of any specific facts or
circumstances which might give rise to a claim being made against the Applicant?
Yes
No
If yes, please provide details:
2.
With respect to the coverages applied for, upon inquiry of any of person qualifying as a Named
Insured under the proposed policy, are there any facts, circumstances, or situations which might
give rise to a claim under the coverage(s) for which the Applicant is applying?
Yes
No
If yes, please provide details:
Physicians and Dentists Questionnaire
Page 3 of 4
© 2015 Philadelphia Consolidated Holding Corp.
02/2015
Clear Application
Print Application
FRAUD NOTICE STATEMENTS
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 AND
SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A
FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL
PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION).
(NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN
PRISON.
APPLICABLE IN COLORADO: 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
POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT
WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO
DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY
INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS
GUILTY OF A FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR
PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY
AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE
RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT
PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN
MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: 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 A DENIAL OF INSURANCE BENEFITS.
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her
knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments
submitted with this Application) are true and complete and may be relied upon by Company * in quoting and issuing the
policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify
the Company of such changes and the Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRINCIPAL, PARTNER OR
OFFICER)
____________________________________________________
SIGNATURE DATE
Produced By: (Section to be completed by Producer/Broker)
PRODUCER AGENCY
PRODUCER LICENSE NUMBER AGENCY TAXPAYER ID OR SS NUMBER
ADDRESS (STREET, CITY, STATE, ZIP)
Physicians and Dentists Questionnaire
Page 4 of 4
© 2015 Philadelphia Consolidated Holding Corp.
02/2015
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Application - Medical Professional36-9341

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Completed 2 July 2020

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