Fillable COVERYS SPECIALTY INSURANCE COMPANY CHIROPRACTOR PROFESSIONAL LIABILITY APPLICATION (Risk Placement Services, Inc.)

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COVERYS SPECIALTY INSURANCE COMPANY CHIROPRACTOR PROFESSIONAL LIABILITY APPLICATION (Risk Placement Services, Inc.)

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COVERYS SPECIALTY INSURANCE COMPANY
CHIROPRACTOR PROFESSIONAL LIABILITY APPLICATION
If CLAIMS MADE COVERAGE is chosen, READ THE FOLLOWING NOTICE:
NOTICE: COVERAGE IS LIMITED TO LIABILITY FOR CLAIMS FIRST MADE AGAINST YOU
DURING THE POLICY PERIOD OR AN EXTENDED REPORTING PERIOD, IF APPLICABLE. PLEASE
REVIEW THE POLICY CAREFULLY AND DISCUSS THE POLICY WITH YOUR INSURANCE
REPRESENTATIVE.
INSTRUCTIONS
1) Answer ALL questions completely, leaving no blanks (use “N/A” if Not Applicable).
2) If you need more space for responses, continue on a separate sheet of paper and indicate question number.
3) The application must be signed and dated by the applicant.
4) If your most recent policy is "claims-made" and you desire to continue coverage back to your "retroactive date," proof of conti
nuous
claims-made coverage must be submitted with this application. (The Declarations Page of your most recent policy is adequate.)
I. INFORMATION
1) Applicant Full Name (including middle initial): Dr. _______________________________________________________
2) SSN ______
_________________ (Last 4 required)____
3) Refer
red By: _______________________________________________
4) Type of Practice: (chec
k one)
□ Individual Independent Contractor with other doctors □ Employee □ Solo Practitioner-
Unincorporated
□ Solo Practitioner-Incorporated □ Professional Corporation with ownership. Tax ID______________
5) Legal
business name of primary practice clinic: ___________________________________
(list any additional locations on a separate sheet)
6) Own
er of Clinic:
7) Pri
mary Practice Address:
County: __
_____________________________
City: ________________________________ State: ____ Zip:__________
Sec
ondary Practice Address (If applicable):
County: __
_____________________________
City: ________________________________ State: ____ Zip:__________
8) Email A
ddress:___________________________________ 8) Office Phone #:_______________________________
9) W
ebsite: _______________________________________ 10) Mobile Phone #:_____________________________
11) Hom
e Phone #:___________________________________ 12) Fax #:______________________________________
13) Do you cu
rrently have Professional Liability Coverage?
□ Yes □ No If yes, is it occurrence or claims made?
□ Claims-made □ Occurrence If claims made, retro date? _______
If no, please provide explanation:
14) Reque
sted Coverage type of form: Professional Liability (check one)
□ Claims-made □ Occurrence
15) Requested Effective Date:
16) Complete the following to extend coverage to an Entity/Corporation you own:
□ N/A
□ Shared Limits (No Additional Charge)
□ Separate Limits (Additional Charges Apply – Not available for a solo professional)
17) Are you requesting an additional insured be added to your policy at an additional charge?
□ Yes □ No
List the legal business name: __________________________________ Relationship: ________________________
II. REQUESTED LIMITS (each incident/annual aggregate) (check one)
□$100k/$300k □$200k/$600k □$400/1.2M □$500k/$1M □$1M/$3M □other:__________________________
Check () here
□ if you are an Indiana resident. Participation in the Indiana Patient’s Compensation Fund is required and your Limit
of Liability will be $400,000/1,200,000.
Check () here
□ if you are a Louisiana resident. Participation in the Louisiana Patient’s Compensation Fund is required and your
Limit of Liability will be $100,000/$300,000.
Check () here
□ if you are a New Mexico resident. Participation in the Louisiana Patient’s Compensation Fund is required and your
Limit of Liability will be $200,000/$600,000 on occurrence basis only.
III. APPLICANT PROFILE
1) Current or projected number of your patient visits each week: ______________
2) List number of hours per week with patients (must include your consulting, paperwork, and lab time related to patient care):
______ _________________ (20 hours or less is part time)
Please check if YOU or YOUR OFFICE performs any of the following procedures in your practice:
Performed by You If Checked, please
indicate the estimated
% of patient time you
utilize this therapy
Acupuncture
Lab work
(done directly by you or staff you supervise in your office)
Colon Irrigation
Invasive/Needle EMG
Hospital Privileges – If current, please list hospital(s)
Manipulation under anesthesia (MUA) – is excluded
Minor Surgery
Animal Adjusting is excluded
.
IV. LICENSURE/EDUCATION
Chiropractic College Attended: _____________________________________________ Graduation Date: ________________
Chiropractor License Number(s) State(s) Date(s) first licensed
(list additional licenses on a separate sheet)
V. ADDITIONAL CHIROPRACTORS
(List all other chiropractors practicing in the same office with you and include all locations. Use separate sheet as needed.)
1) Name: ________________________________________________________________ Check () here
□ if currently insured
2) Name: ________________________________________________________________ Check () here
□ if currently insured
VI. RISK MANAGEMENT
1) Have you taken a continuing education patient safety or risk management course in the last two years? □ Yes □ No
2) Is patient progress documented each visit?
□ Yes □ No
3) Your patient chiropractic record is:
□ handwritten □ travel card □ dictated □ software: specify _______________________
4) If necessary, would you refer to other healthcare practitioners, those patients who require additional clinical assessment,
diagnosis and treatment outside the scope of Chiropractic?
□ Yes □ No
5) Do you utilize informed consent forms?
□ Yes □ No
6) Do you require signed release forms for the release of medical records?
□ Yes □ No
7) What resource(s) does your practice utilize regarding patient safety standards and office procedures, such as patient education
materials, office manual, other?
8) Are you an active (dues paying) member of a Chiropractic Association? □ Yes □ No
(if yes, specify): ___________________________________________________________________________________
9) Have you or (the corporation you own) ever been the subject of a Licensing Board investigation, complaint, reprimand or
disciplinary action.
□ Yes □ No
If an Administrative Hearing has ever been initiated against you, please complete and attach an Administrative Hearing
Incident Form.
10) Have you ever had your chiropractic license suspended, revoked, voluntarily surrendered, or been placed on probation in any
state?
□ Yes □ No
11) Have you ever been denied, cancelled, refused renewal or accepted only on special terms for professional liability insurance
coverage? (Please indicate even if already reported)
□ Yes □ No
NOTE: MISSOURI RESIDENTS DO NOT RESPOND TO THIS STATEMENT
12) Have you ever been convicted of any crime, other than a minor traffic violation in any state or country?
□ Yes □ No
If you answered yes to any questions between 9-12, please attach a separate sheet with full particulars.
VII. CLAIM HISTORY
1) Do you or your insured entity have any current or prior claims? □ Yes □ No
If yes, please submit current status and a detailed explanation for each loss. Request and complete our supplemental claims
form for each loss/claim.
2) Are you aware of any circumstance, accident or loss, including those arising from your billing practices that has not been
reported to your insurance carrier but which may result in a claim or suit being made against you, your predecessors in
business or against any past or present partner(s)? □ Yes □ No
If yes, give dates, allegations and disposition of each claim or suit.
VIII. HISTORICAL PROFESSIONAL LIABILITY INSURANCE INFORMATION
List all Professional Liability policies for each of the past five years. When referring to your prior coverage, please list either
Claims Made or Occurrence.
Policy Period Insurer Limits Premium Prior Policy Occurrence or
claims made
IMPORTANT
NOTICE
THE
UNDERSIGNED DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AGREES
THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION
AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL IMMEDIATELY NOTIFY THE COMPANY
OF SUCH CHANGES, AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS,
AUTHORIZATION OR AGREEMENT TO BIND THE INSURANCE.
SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY TO COMPLETE THE
INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A
POLICY BE ISSUED.
ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY IN CONJUNCTION WITH THE
APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THE APPLICATION AND MADE A PART HEREOF.
THE EARLIEST EFFECTIVE DATE FOR WHICH A POLICY MAY BE ISSUED IS THE DATE THIS APPLICATION IS
RECEIVED IN OUR OFFICE.
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 ACT,
WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO ALABAMA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT
CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO RESTITUTION FINES OR
CONFINEMENT IN PRISON, OR ANY COMBINATION THEREOF.
NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA 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 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
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 AUTHORITIES.
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 INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY
FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
NOTICE TO KANSAS APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD,
PRESENTS, CAUSES TO BE PRESENTED OR PREPARED WITH KNOWLEDGE OR BELIEF THAT IT WILL BE
PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN,
ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION OR
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 MATERIAL 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.
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 A DENIAL OF INSURANCE BENEFITS.
NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE
OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY
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 MINNESOTA APPLICANTS: A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS
COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.
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 YORK 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED
FIVE THOUSAND DOLLARS 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 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 ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE
POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY
(365:15-1-10, 36 §3613.1).
NOTICE TO OREGON 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, MAY BE GUILTY OF A
FRAUDULENT ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL
PENALTIES.
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
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 SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON 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 VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN
APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES
UNDER STATE LAW.
Applicant’s Name:
Applicant’s Signature: Date:
Title:
Agent/Producer Name: License #:
Signature of Agent/Producer:
Address:
Phone: _____________________ Fax: ___________________
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COVERYS SPECIALTY INSURANCE COMPANY CHIROPRACTOR PROFESSIONAL LIABILITY APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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