Fillable Coverys Podiatry Preferred Premium Indication (Risk Placement Services, Inc.)

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Coverys Podiatry Preferred Premium Indication (Risk Placement Services, Inc.)

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* Premium indications provided are not firm quotations and are not bindable. Terms, limits, deductibles, conditions and price may change
upon receipt, review and acceptance of a completed application and supporting documentation by the company. A binding quotation will
not be issued without the company’s full underwriting.
Name
Street
City County State Zip
Phone Fax
Email
RISK MANAGEMENT PRACTICES
Risk management course completed within the past year?
Yes No Date: _________
What percentage of your practice involves (*includes IV
Conscious Sedation):
DIABETIC PATIENTS
What percent of your patient load involves diabetic patients?
_______ 0-15% _______ 16-30% _______ 31-5
0%
_______ 51-70% _______ 71-100%
CURRENT POLICY INFORMATION
Carrier:
Expiration Date: __________Retroactive Date: _________
Type:
Claims Made Occurrence
Limits:
$100,000/$300,000 $250,000/$750,000
$1 Million/$3 Million Other:
Annual Premium: $
PRACTICE PROFILE
Date Practice Started: ________________
Are you practicing as a
Owner Employee Independent Contractor
Number of Podiatrists in your practice:
Employees Independent Contractors
Type of Practice:
Solo Partnership Corporation
Number of hours worked per week: ________
Are you board certified/eligible?
Yes No
Professional Organizations to which you belong (ACFAOM,
APMA, ACFS, ABPS, AAFS, others): ____________________
___________________________________________________
SURGICAL PROCEDURES PER YEAR
Estimated number of the follow ing surgeries performed per year:
Joint or other Implants or Prosthesis _________
Ankle/Joint /Lower Leg Surgery _________
Tendon Transfer Surgery _________
Achilles Tendon Surgery _________
Laser Surgery _________
Minimal Incision Foot Surgery _________
Bunion Surgery – Non-Osteotomy _________
Bunion Surgery - Osteotomy _________
Hammertoe Surgery _________
Cryosurgery/Chemosurgery _________
Amputation _________
Arthoereisis _________
Other (describe): ___________________________________
__________________________________________________
LOSS and DISCIPLINARY ACTION INFORMATION (settled or pending)
No Claims or Disciplinary Actions Details of all open/closed claims and disciplinary actions are attached
Coverys Podiatry Preferred
Premium Indication
_______ Local Anesthesia
_______ *General Anesthesia
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Coverys Podiatry Preferred Premium Indication (Risk Placement Services, Inc.)

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Completed 30 July 2020

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