Fillable Chiropractor App Chiropractor New Business Application (Kinsale Insurance)

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Chiropractor App Chiropractor New Business Application (Kinsale Insurance)

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Page 1 of 8
Kinsale Insurance Company
P.O. Box 17008
Richmond, VA 23236
(804) 289-1300
www.kinsaleins.com
Instructions to the Applicant – please complete this application in ink and answer all questions completely. Attach extra
sheets as necessary should you run out of space provided. An incomplete or illegible application cannot be processed.
Completion of this application neither binds coverage nor guarantees that a policy will be issued.
CHIROPRACTOR NEW BUSINESS APPLICATION
Provide a fully completed application, signed and dated by the owner, partner, or officer not earlier than 45 days before
the proposed effective date of coverage.
If a question is not applicable, then state “N/A”.
The following information must be submitted with the completed application:
- Copy of your current professional liability insurance Declarations Page (claims made policies
must reflect the retroactive date)
- Copy of your Curriculum Vitae
- Copy of all licenses and board certifications
- Copy of your business letterhead
- Copy of all advertising that you use
- Copy of all reporting endorsements previously issued to you
- 5-year company loss runs, valued within the last 60 days
PERSONAL INFORMATION
Applicant’s Name and Degree designation(s): _____________________________________________________________
Social Security Number: ________ - ______ - ________ Date of Birth _____ / _____ / ________
Mailing Address: ___________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Practice Address: ___________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
E-Mail Address: ________________________________ Website Address: ___________________________________
Are you a U.S. Citizen? Yes No If no, indicated status and date of entry _________________________________
PRACTICE SPECIALTY AND EDUCATION
1. License Information
a. Chiropractic License Number(s): __________________________________________________________
b. State(s) Licensed: ______________________________________________________________________
c. Are you licensed to practice any other health care practices? YES NO
If yes, please circle: MD DO DPM ND RN RPT LAC MIDWIFE Other: _____________
2. Education: _______________________________________________________ __________________
Chiropractor College or University, City, State, County Year of Graduation
Page 2 of 8
3. List all locations and dates where you have practiced in the last 10 years:
Practice Name City/State From To
4. Is the Applicant a “Covered Entity” under the Health Insurance Portability and Accountability Act of 1996
(HIPAA) Privacy? If yes,
a. Has the Applicant implemented procedures to comply with the HIPPA Privacy Rule? YES NO
b. Provide the name and title of the Applicant’s Privacy Officer: __________________________________
PRACTICE INFORMATION
5.
Please describe your practice:
Sole Proprietorship (unincorporated) ____________________________________________________________
Professional Corporation ___________________________________________Applicant’s % Ownership: _____%
Employee, Associate, or Independent Contractor with ________________________________________________
6. Are you requesting that the entity be named on your policy? If yes, please forward articles of
incorporation.
YES NO
7. Please tell us how many
a. Hours per week you practice chiropractic: ____________________________________
b. Patient visits you handle annually: __________________________________________
8. Approximate gross annual income from your practice
Less than $50,000 $100,000 - $149,999 $200,000 or more
$50,000 - $99,999 $150,000 - $199,999
9. Do you anticipate any changes in your practice in the next 12 months? If yes, please attach details
YES NO
SPECIFICS OF PRACTICE/PROCEDURES
10. Please indicate those procedures or devices used in your practice:
Yes No Yes No
General meric adjusting
Upper cervical specific
Instrumental adjusting
Gonstead/diversified
Direct non-force
Sacro-occipital
Hydroculator/heat packs
Electrical stimulation
Ice-cryotherapy
Trigger point therapy
Cold laser
Activator
Galvanci
Ultraviolet
Ultrasound
Massages
Short wave diathermy
Kinesiology
Mechanical traction
Whirlpool
Stressology
Internalcoccyx adjustment
Gemstone therapy
Toftness device
Colonic irrigations
Treat cancer
Treat epilepsy
Manipulation under anesthesia
Prenatal care & normal deliveries
Page 3 of 8
11. If the answer to any of the questions below is “no,” please attach details. Do you:
a. Use the Georges test, the Vertebral Artery Ischemia Test or the Cerebrovascular
Craniocervical Function Test when initially seeing a patient or when seeing a patient
you have not seen for six months? If no, please describe how you assess vascular flow.
If an unusual finding results, do you refer the patient to the appropriate medical
practitioner? ………………………………………………………………………………………………………………….
YES NO
YES NO
b. Make a differential diagnosis? ……………………………………………………………………………………….
YES NO
c. Always record the patient’s account of his/her progress? ……………………………………………..
YES NO
d. Always record objective findings? ………………………………………………………………………………….
YES NO
e. Always record details of treatment procedures? …………………………………………………………..
YES NO
12.
If the answer to any of the questions below is “yes,” please attach details. Do you:
a. Perform acupuncture? …………………………………………………………………………………………………..
If yes, do you use the National Council on Certification of Acupuncturists (NCCA) clean
needle technique? …………………………………………………………………………………………………………
Date of last NCCA exam taken and passed _____________________________
If no, do you use disposal needles? (If no, please attach details) …………………………………..
YES NO
YES NO
YES NO
b.
Dispense or prescribe: Drugs? ………………………………………………………………………………………
Vitamins? …………………………………………………………………………………
YES NO
YES NO
c.
Use x-ray or imaging in treatment determination? ……………………………………………………….
YES NO
d.
Engage in any procedure, other than acupuncture or the drawing of blood for
diagnostic purposes, requiring the penetration of the skin? ………………………………………….
YES NO
e. Perform investigation or experimental research or therapy on human patients? …………
YES NO
f. Perform animal chiropractic? ………………………………………………………………………………………..
YES NO
STAFF
13. Please indicate the number of professional employees, volunteers and independent contractors (not including
yourself). # of Employees and # of Independent
Volunteers Contractors
Chiropractor
Chiropractor Assistant
Nurses, Licensed Practical
Nurses, Practitioner
Nurses, Registered
X-ray Technician
Laboratory Technician
Physical Therapist
Massage Therapist
Student/preceptors
Other ____________________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
NOTE: If you require any of the above to be Named Insureds, please submit a separate application for each individual.
14.
Are all the above individuals licensed in accordance with applicable state and federal
regulations? If no, please attach explanation.
YES NO
Page 4 of 8
15. Are you engaged in any business other than the practice of chiropractic?
If yes, please attach details.
YES NO
16. Do you own (wholly or in part), operate or administer any hospital, nursing home, surgi-
center, clinic or other facility where healthcare services are customarily rendered?
YES NO
17. Do you, or the entity named in Question 5, contract to provide professional services to any
individual, entity or governmental entity? If yes, please attach details.
YES NO
18.
Are you affiliated with any hospitals? If yes, please provide name(s), city, state
YES NO
19. Please list any professional societies/organizations in which you are currently a member: __________________
______________________________________________________________________________________________
PRIOR POLICY AND LOSS INFORMATION – Questions 20-34 provide details for all “YES” answers
20. Has your medical or narcotics license ever been limited, suspended, revoked, denied, or
investigated by any licensing board or regulatory agency?
YES NO
21.
Has your board certification or membership in any medical society or association ever been
refused, suspended, revoked, or voluntarily surrendered?
YES NO
22.
Have your hospital privileges ever been suspended, restricted, denied, placed in probationary
status, or revoked?
YES NO
23.
Have you ever been charged with, or convicted of a crime other than minor traffic violations?
YES NO
24.
Have you ever been diagnosed or treated for alcoholism, drug addiction, any chemical
dependency, or mental or chronic physical illness?
YES NO
25. Has any fee or professional relations complaints been registered against you with your medical
association, hospital, or a state licensing authority?
YES NO
26.
Provide the following information pertaining to your past 5 years of professional liability insurance coverage:
Carrier
Policy Period
Policy Limits
Deductible
Claims Made? (Y/N)
Retro Date
27. Have you ever practiced without professional liability insurance?
YES NO
28.
Do you have professional liability insurance for work you do elsewhere? If yes, please explain on
page 5
.
YES NO
29.
Have you ever had any insurance company decline, cancel, rescind, or non-renew any
professional liability insurance policy?
YES NO
30.
Have you ever been involved in any professional liability claim or suit, either directly or
indirectly?
YES NO
31. Are you aware of any known losses or claims that have not been reported to a prior insurance
carrier or any other source from which payment might be made?
YES NO
32.
Are you aware of any request for medical records by a patient or his/her attorney which might
result in a claim?
YES NO
Page 5 of 8
REQUESTED COVERAGE
(NOTE: The Company may not offer or quote requested coverage)
Requested Effective Date:____________ Requested Retroactive Date:_______________
Requested Limits of Liability Requested Deductible
___ $100,000/$300,000 ___ $5,000
___ $200,000/$600,000 ___ $7,500
___ $250,000/$750,000 ___ $10,000
___ $500,000/$1,500,000 ___ $25,000
___ $1,000,000/$3,000,000 ___ $50,000
___ $2,000,000/ $6,000,000 (VA only) ___ Other $_____________
SUPPLEMENTAL INFORMATION
Use this page to as needed to address questions referenced within the application or to provide information
you deem pertinent to our review of your application
33. Are you aware of any prior professional liability carrier refusing coverage for, or declining to
accept a report of a specific act, omission, or circumstance involving particular and specific
professional services that may result in a claim, threat of claim, letter of intent, adverse result
notice, or attorney contact?
YES NO
34. Have all circumstances that might reasonably lead to a claim or suit, even if you believe them
to be without merit, been reported to your current or prior professional liability company?
Indicate N/A if you are not aware of any such circumstances . If yes, how many? ____ please
complete a supplemental claims form for each.
YES NO
N/A
Page 6 of 8
• I have
STATEMENT OF NO KNOWN CLAIMS or CIRCUMSTANCES
no known losses or claims
• I have
that have not been reported to my prior insurance carrier or any other source from
which payment might be made;
no knowledge
• I have
of acts, omissions or circumstances that relate to a professional service which could reasonably
result in a claim, that has not been reported to a prior insurance carrier;
no knowledge
• I have
of any request for medical records by a patient or their attorney which might result in a claim;
no knowledge
• I have
or information relating to service or services on a Board which might result in a claim; and
no knowledge
of any prior professional liability carrier refusing coverage for, or declining to accept a report of a
specific act, omission or circumstance involving particular and specific professional services that may result in a claim,
threat of claim, letter of intent, adverse result, or attorney contact.
My signature on page 9 below confirms the above statements unless otherwise noted
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MARYLAND,
MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA,
OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING
APPLICANTS: In some states, 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, for the purpose of misleading, conceals information concerning any fact material thereto, may
commit a fraudulent insurance act which is a crime in many states.
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 policy holder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to
the Colorado Division of Insurance within the Department of Regulatory Agencies.
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 insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a
crime punishable by fines or imprisonment, or both.
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.
FRAUD WARNING
Page 7 of 8
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 denial of insurance benefits.
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 MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 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/she 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 a any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
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 a 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.
NOTICE TO TENNESSEE 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 VIRGINIA 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above
statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material
fact.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of any
policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such
changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application and
made a part of this application.
Applicant: __________________________________________ Title: _________________________________
Applicants Signature: _______________________________ ______ Date: ________________________________
Agent/Broker Name: _________________________________________________________________________
T INFORMATIPPLEMENT CLAIM / INCIDENT INF FRAUD OR
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Page 8 of 8
If reporting more than one claim or incident, please photocopy and complete a separate form for each. Attach additional
sheets if necessary for adequate explanation.
All questions must be answered or marked Not Applicable (N/A), and each
sheet must be signed.
Name of Patient:____________________________________________ Age:______ Sex:_______
Incident Claim
Date reported to insurance company: ______________
Name of insurance company: _______________________________________________
Date of incident and your treatment: _______________________________________________________
Allegations / Circumstances: ___________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Additional Defendants: _______________________________________________________________________
What is the present condition of the patient?______________________________________________________
___________________________________________________________________________________________
Suit threatened, no action taken Court outcome in YOUR favor: Unresolved/Open
STATUS OF CLAIM
Suit filed but dropped by claimant Jury verdict Awaiting mediation
Summary judgment in your favor Directed verdict Awaiting court action
Suit settled out of court Court outcome in favor of plaintiff: Reserve amount: $__________________
Date claim paid: _____________ Jury verdict
Amount paid: $_____________ Directed verdict
Did you want to settle? Yes No Amount of loss payment: $_____________________
Name and address of the attorney assigned to your case: ____________________________________________
___________________________________________________________________________________________
To your knowledge, was any settlement paid by another party involved (i.e., your P.A., P.C., partners, employees, etc.)?
Yes: No:
Explain in detail what action(s) you have taken to prevent recurrence of this type of claim:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Signature: __________________________________ Date:_____________________
Printed Name: __________________________________
SUPPLEMENTAL CLAIM/ INCIDENT INFORMATION
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Chiropractor App Chiropractor New Business Application (Kinsale Insurance)

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Completed 16 July 2020

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