Fillable Chiropractic Professional Liability Application Malpractice Insurance (Philadelphia Insurance Companies)

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Chiropractic Professional Liability Application Malpractice Insurance (Philadelphia Insurance Companies)

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Chiropractor Professional Liability Page 1 of 8
- FL 07/12
.
Malpractice Insurance
Chiropractic Professional Liability Application
CLAIMS MADE POLICY
NOTICE: Except to such extent as may otherwise be provided herein, the coverage of this policy is limited
generally to liability for only those claims that are first made against the insured while the policy is in force.
Please review the policy carefully and discuss the coverage with your insurance agent.
A. PERSONAL
1.
Full Name: Last: First: Middle:
2.
Date of Birth:
Age: Male:
Female:
Social Security Number or FEIN:
3.
Home Address:
City:
State:
Zip Code:
4.
Home Phone:
5.
Chiropractic License Number: State of Issuance:
6.
As a Doctor of Chiropractic, you practice as a (ONLY ONE):
SOLE Practitioner CORPORATE Shareholder
PARTNERSHIP ASSOCIATE (Employed / Contracted)
B. PRACTICE
1.
Office Address:
City: County:
State: Zip Code:
2.
Office Phone: FAX:
Cell Phone: E-Mail:
3.
Years at Location:
4.
Do you have a financial responsibility to any other practice location(s)?
Yes No
(If Yes, attach address(es) and explanation on a separate sheet.)
5.
Are you incorporated?
Yes No
PI-CPHC-APP-DC
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-FL 07/12
C. STAFF / ASSOCIATES
1.
Indicate the n
umber
of personnel in your practice location(s) as follows (mark zero if not applicable):
Chiropractors (other) (attach names) Physical Therapists (licensed)
Registered Nurses (licensed) Clerks, Receptionists, Technicians,
Physiotherapists and other non-licensed
2.
Approximately how many patient visits are treated by you and/or by the above staff during a typical
Practice week?
3.
Approximately how many hours of Face Time do you spend during a typical Practice week?
4.
Other than noted above, are there any other licensed medical professionals that are associated with
your practice? Yes No (If Yes, give names, specialties, and extent of association on a
separate sheet.)
5.
Do you perform initial and interim examination of patients? Yes No
6.
Do you use progress notes that include subjective and objective findings in charting patient
visits? Yes No
D. NEW PATIENT PROTOCOL
1.
When a new patient presents to you for chiropractic care, prior to treatment do you (must mark each):
Obtain a medical history? Yes No
Formulate a differential diagnosis for treatment? Yes No
Obtain signed consent to treat? Yes No
Discuss the treatment planned? Yes No
Perform a physical exam? Yes No
Discuss the patient’s financial responsibility? Yes No
2.
With new patients, percent (approximately) that present to you with the following major complaint(s) of (can
exceed 100%):
Cranial Cervical Lumbar
Extremity Dorsal or
Thoracic
Other:
3.
Approximately how many new patients are treated by you during a typical practice week?
E. MANIPULATION
1.
Check any/all general techniques and specific procedures used in patient care that are listed below:
General Meric Adjusting:
Meric Gonstead Diversified
Motion Palpation Pierce-Stillwagon Thompson
Upper Cervical Specific:
Toggle Hole In One
Grostic Orthogonal
%
%
%
%
%
%
P
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-FL 07/12
Instrumental Adjusting:
Life Cervical Pettibon Spinal Bio Physics
Activator Equalizer
Kinesiology:
Bennett Reflexes Reflexology Applied Kinesiology
Direct Low-Forge:
Direct Non-Force Technique Jenness Freeman
Trigger Points Receptor Tonus Toftness
Sacro-Occipital:
Logan Basic:
Cox-Mc Manis:
F. THERAPIES
1.
Do you do Meridian therapy? Yes No
(If Yes, check all
you do):
Acupressure Electric Acupuncture
Needle Acupuncture Laser Acupuncture
2.
Check any/all physiotherapies used in patient care that are listed below:
Traction:
Mechanical Motorized Inversion Intersegmental
Equipment:
Short-Wave Diathermy
Low/ Hi Volt Galvanism
Tens Current Inferential
Infra Red Ultraviolet
Accuscope Ultrasound
Whirlpool Muscle Stimulating Current
G. X-RAYS
1.
Do you provide your own x-rays at your practice location? Yes No
(If Yes, answer below)
Does everyone who takes x-rays have proper and current certification/training? Yes No
Do you always use the 10-day rule for x-raying females of child-bearing age? Yes No
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-FL 07/12
H. SPECIALTIES
1.
In your prac
tice of chir
opractic, do you ever provide patient care as follows (must mark each):
Venipuncture: Yes No Obstetrics: Yes No
Reichian Therapy: Yes No Invasive Surgery: Yes No
Sinus irrigation: Yes No Chelation Therapy: Yes No
Gynecological Exams: Yes No Colonic Irrigation: Yes No
Proctological Exams: Yes No
I. REFERRALS
1.
Do you have an established and working relationship with any of the medical specialists listed below?
(Check all that apply)
Neuro Specialist Orthopedist Radiologist
Vascular Specialist Internist General Practitioner
2.
Do you have an established relationship to refer directly for diagnostic imaging? Yes No
J. MEDICAL POLICY
Select the options that best describe your medical policy to the situation listed below (only one per selection
group):
When a patient first presents with signs and/or symptoms of cerebrovascular insufficiency, do you:
1.
Assess cerebral flow (i.e. palpate pulses, ausculate for bruits, Adson maneuver, etc.) prior to any cervical
spine manipulation:
Always Usually Occasionally Never
2.
Document your findings prior to any cervical spine manipulations:
Always Usually Occasionally Never
3.
Refer the patient to a specialist and/or non-invasive diagnostic imaging if the signs and/or symptoms are not
resolved with normal local care:
Always Usually Occasionally Never
K. BUSINESS POLICY
Check any/all of fee and payment formats used in patient care that are listed below:
1.
Fees are collected:
Cash/Check Charge Card Barter
Statements In Advance
On insurance assignment ( With / Without out of pocket)
On case contract ( Installments In advance)
2.
No cost services are allowed:
Indigent
Introductory Referral
Community Service Professional Courtesy Educational
3.
Do you use a collection agency on past due accounts? Yes No
L. EDUCATION
1.
D.C. College: Month/Year Graduated:
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-FL 07/12
2.
Are you currently a member of and/or affiliated with any chiropractic Association and/or Society?
Society? Yes No (If Yes, identify)
3.
List any special chiropractic credentials and/or status that you have obtained:
M. CONFIDENTIAL INFORMATION
Answer the following questions and if your response is Yes, then describe on a separate sheet:
1.
Are you gainfully engaged/employed in any other profession and/or professional activity? Yes No
2.
Have you ever had professional liability insurance canceled or renewal refused? Yes No
3.
Have you ever used an intoxicant, narcotic, or other psychoactive or depressant drug to the extent that it has
interfered with your ability to perform professional duties? Yes No
4.
Have you ever been treated for alcoholism or drug addiction? Yes No
5.
Have you ever been involved in the loss or removal of a medical provider number? Yes No
6.
Have you ever had any state license to practice chiropractic revoked, suspended, or involuntarily
surrendered? Yes No
N. CLAIMS HISTORY
Provide patient names, dates, circumstances, details, status, etc. on a separate sheet for
any "Yes" answer below.
1.
Has the Applicant been involved in any malpractice claim(s) or suit(s)? Yes No
2.
Is the Applicant aware of any incidents which have occurred that might give rise to a claim in the future?
Yes
No
3.
Is the Applicant aware of any other circumstance
s, injury, accident, error, omission, or offense which may
result in a claim being made against the Applicant or any of its predecessors in practice or any of the past
or present partners, owners, officers, or employees? Yes No
O. INSURANCE INFORMATION
1.
Do you currently have Malpractice Insurance? Yes No
If Yes, who is the carrier:
What are your coverage limits
: $
2.
What is your current Retroactive
Date, if any? Retroactive Date:
3.
What limits of coverage are you applying for?
100/300 200/600 500 / 1.5Mil 1 Mil / 3 Mil
4.
What is your proposed effective date of coverage?
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-FL 07/12
5.
Do you currently have premises liability? Yes No
If Yes, who is the carrier
:
6.
Do you want coverage for your corporation, limited liability company or limited
liability partnership? Yes No
If Yes, what is the name of the entity:
P. PRACTICE REPRESENTATIONS
1. The undersigned Applicant represents, as a condition precedent to coverage, that he/she will not do
any of the following: practice obstetrics, perform procedures under 2 weeks of age, perform any
invasive surgical procedure, and/or do acupuncture with needles.
____________________________________________________________________
Signature Date
Q. MISCELLANEOUS ACKNOWLEDGEMENTS / AUTHORIZATION
1.
I hereby authorize release and exchange of information between my medical association or society and their
insurance consultants, any hospital I presently or previously held staff privileges with, and prior insurance
carriers involving past and future underwriting and claims matters. I further agree that the organization
releasing the information, its agents, servants and employees, shall not incur any liability as a result of any
information released or furnished pursuant to this authorization, including any errors, omissions, or mistakes
contained in such released information.
2.
I understand that the policy being applied for does not cover liability for others which I may have assumed
under any contract or agreement. I understand that the policy being applied for is limited to claims for
professional liability and that it does not provide coverage for property insurance, comprehensive general
liability, owned or non-owned automobiles, premises liability, or any other coverage.
3.
Submission of this application (signed or unsigned) to the company – with or without permission – does not
bind insurance coverage. Rather, insurance coverage will be put in force only when the insurance company
issues a written “Confirmation of Coverage’ or insurance policy. The insurance company will not issue a
“Confirmation of Coverage” until after it has:
a. Received and approved a completed application from you, and
b. Issued a written premium quotation to you based upon your application and certain other information,
and
c. Received from you a written request to place coverage in effect, and
d. Received from you either 100% of the correct premium, taxes, and fees which were quoted in the
written premium quotation discussed in “3b” above, or 25% of the correct premium and 100% of the
taxes, and 100% of the fees which were quoted in the written quotation discussed in “3b”.
____________________________________________________________________
Signature Date
MISCELLANEOUS REPRESENTATIONS
1.
The undersig
ned Applic
ant represents that if the Applicant selects the insuran
ce which is provided on a claims
made policy, then they are
aware of the following: It only covers occurrences which take place during the
policy period and then only if the claim is first made to the company during the policy period or during a 60-
day reporting period commencing with the termination of the policy. The policy allows, for an additional
premium, an extended reporting period option. A sample policy is available on request.
____________________________________________________________________
Signature Date
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Chiropractor Professional Liability
PI-CPHC-APP-FL 07/12
Page 7 of 8
2.
The undersigned Applicant represents, as a condition precedent to coverage, that he/she will provide
immediate written notice to the insurance company, prior to the inception of any coverage which may be
offered by the insurance company, of any occurrence, event, claim or suit of which the Applicant becomes
aware, subsequent to completion of this application, but prior to the inception of any coverage which may be
offered by the insurance company.
The Applicant further understands that failing to provide written notice to the insurance company, as
provided in Paragraph 1 above, will cause any coverage to be rescinded.
3.
The undersigned Applicant has read and understands this application and represents, as a condition
precedent to coverage, that all statements set forth herein are true, complete and accurate. The insured
understands that this application will be relied upon by the insurance company as it determines whether or
not it will offer coverage (and, if so, the price at which such coverage will be offered). As such, this
application will become part of the insurance contract (if such a contract is ultimately issued) and any false
representation made on this application will cause any coverage to be rescinded.
Signature Date
False Information
FRAUD NOTICE STATEMENT
NOTICE TO FLORIDA RESIDENTS 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.”
Signature
The Undersigned represents that to the best of his/her knowledge and belief the statements set forth herein are
true. The Undersigned further declares that any occurrence or event that takes place prior to the effective date of
the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately
be reported in writing to the insurance company. The insurance company may withdraw or modify any outstanding
quotations and/or authorization or agreement to bind the insurance. The insurance company is hereby authorized
to make any investigation and inquiry in connection with the information, statements and disclosures provided in
this Application. The signing of this Application does not bind the Undersigned to purchase the insurance, nor does
the review of this Application bind the insurance company to issue a policy. It is agreed that this Application shall
be the basis of the contract should a policy be issued. This Application will be attached and become a part of the
policy.
Name (Please Print/Type) Title (
MUST BE SIGNED BY THE PRESIDENT,
CHAIRMAN OR EXECUTIVE DIRECTOR
)
_______________________________________
Signature Date
The above signed represents that he/she is authorized and has the power to complete and execute this Application,
including the Representation Statement on behalf of the Applicant and their respective Directors, Officers or other
insured persons.
Produced By: (Section to be completed by Producer)
Producer Agency
Producer License Number Agency Taxpayer ID or SS Number
Address (Street, City, State, Zip)
Chiropractor Professional Liability
PI-CPHC-APP-FL 07/12
Page 8 of 8
ADDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please
identify the question number to which you are referring.
_____________________________________________________________
Signature Date
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Chiropractic Professional Liability Application Malpractice Insurance (Philadelphia Insurance Companies)

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Completed 7 November 2020

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