Fillable Dentists And Oral Surgeons New Business Application (Kinsale Insurance)

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Dentists And Oral Surgeons New Business Application (Kinsale Insurance)

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  • 171 check-boxes
  • 269 other fields

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Page 1 of 12
DENTISTS & ORAL SURGEONS NEW BUSINESS APPLICATION
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.
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
5-year company loss runs, valued within the last 30 days
PERSONAL INFORMATION
Applicant’s Name: __________________________________________________________________ DDS DMD
Date of Birth _____ / _____ / ________
Last four digits of SSN: __________
Are you a U.S. Citizen? YES NO
Home Address: _____________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Mailing Address: ____________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Website: _____________________________________
Email: ____________________________________________
Provide the following information for all states in which you are license to practice:
State
% of Practice
License #
Active
Inactive
Temporary
Pending
Federal DEA License Number: # ____________________________ Status: ____________________________________
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 10
PRACTICE SPECIALTY AND EDUCATION
1. Please indicate your specialty:
General Dentistry
Oral Radiology
Oral Pathology
Pediatric Dentistry
Periodontics
Oral and Maxillofacial Surgery
Orthodontics
Prosthodontics
Dental Anesthesiology
Endodontics
Other: _________________________________________________
2. Complete the following:
Name of Institution
Degree/Specialty
Completed?
Year Completed
Dental School
_______________________________
________________
YES NO
____________
Residency
_______________________________
________________
YES NO
____________
Additional Training
_______________________________
________________
YES NO
____________
3. Are you a Foreign Dental School Graduate? YES NO Date you began practicing in the U.S. _____ /________
4. Indicate the number of CE hours you have completed in past two years: _______
5. Have you participated in any risk management/loss prevention services in the past 12 months? YES NO
6. Of which dental societies and/or associations are you a member?_________________________________________
______________________________________________________________________________________________
PRACTICE INFORMATION
7. Type of Practice:
Solo Unincorporated
Partnership
Solo Incorporated
Professional Association
Corporation
Employed Dentist: By Whom: _________________________________
Limited Liability Company
Contracted Dentist: By Whom: ________________________________
8. Entity Name:______________________________________________________ Applicant’s Ownership: ______%
9. Are you requesting that the entity be named on your policy?
YES NO
11. Principal Practice Address:
___________________________________________________________________________ ______ % of Practice
STREET CITY STATE ZIP
12. Additional Practice Location(s):
___________________________________________________________________________ ______ % of Practice
STREET CITY STATE ZIP
___________________________________________________________________________ ______ % of Practice
STREET CITY STATE ZIP
Page 3 of 10
13. List all locations and dates where you have practiced in the last 10 years:
Practice Name
City/State
Specialty
From
To
OFFICE STAFF
14. Do you employ, contract with, or supervise any dentists? If yes, provide details on page 7.
YES NO
15. Do you share office space or have an expense sharing arrangement with any other dentist not
mentioned above?
If yes, please provide details on page 7.
YES NO
16. Please complete the staff table:
Type
Number
Employed
Coverage
Desired
Number
Contracted
Insured
Elsewhere?
Dentist*
YES NO
YES NO
Dental Assistant
YES NO
YES NO
Dental Technician
YES NO
YES NO
Dental Therapist
YES NO
YES NO
Hygienist
YES NO
YES NO
Physician*
YES NO
YES NO
Physician Assistant
YES NO
YES NO
Surgeon Assistant
YES NO
YES NO
CRNA*
YES NO
YES NO
Nurse (RN, LPN, LVN)
YES NO
YES NO
X-Ray Technician
YES NO
YES NO
Other
YES NO
YES NO
* Separate application must be submitted for each if coverage is desired
SPECIFICS OF PRACTICE/PROCEDURES
17. Average Weekly Practice Hours:
___________
18. Average Weekly Patient Encounters:
___________
19. Do you work for any Locum Tenens companies as an employee or independent contractor?
If yes, indicate number of hours worked each month: ____
YES NO
20. Does the Locum Tenens Company provide you with Professional Liability insurance?
If yes, provide a copy of the COI.
YES NO
21. Have there been any changes in your specialty or practice activities within the past 10 years? YES NO
If yes, explain: ___________________________________________________________________________________________________
_______________________________________________________________________________________________________________
22. Do you anticipate any changes in your specialty or practice activities in the next year? YES NO
If yes, explain: ___________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Page 4 of 10
23. Do you perform any procedure not routinely performed by others practicing in your specialty YES NO
or subspecialty? If yes, explain: _____________________________________________________________________________________
__________________________________________________________________________________________________________________
24. Provide the following information for all hospitals and surgery-centers where you are currently on staff:
(If no hospital privileges, attach protocol for patient admission)
Name of Facility City/State % of Work Type of Privileges
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
25. Are you employed full-time or part-time by the federal, state, or local government, or are you on
active military duty? If yes, explain on page 7.
YES NO
26. Do you treat patients in a nursing home, similar care facility, or correctional facility?
If yes, provide the percentage of practice in each:
YES NO
Name(s) of Facilities:
____% nursing home
____% similar care facility
____% correctional facility
____________________________________________________________
____________________________________________________________
____________________________________________________________
27. Are you now or have you ever performed experimental or investigational procedures or
prescribed/dispensed experimental drugs? If yes, please explain on page 7.
YES NO
28. Do you endorse any products or participate in any activity which offers professional advice to the
public, including but not limited to newspaper columns and broadcasts? If yes, please explain on page 7.
YES NO
29. Do you render care or perform consultations outside the state of your primary office location
including but not limited to the use of telecommunication technology as a medium for rendering
dental services?
If yes, please explain on page 7.
YES NO
30. Do you wire jaws closed for the purpose of weight loss?
If yes, provide annual number performed ________
YES NO
31. If you use Local Anesthesia only, check here
If other types of anesthesia are administered, please complete the table below:
Inhalation Conscious
Sedation
Oral Conscious
Sedation
Parenteral Conscious
Sedation
Parenteral Deep
Sedation
General
Anesthesia
% of patients under age 18
Drugs used
Location performed: Office (O),
Surgi-Center (S), Hospital (H)
Administered by:
You, Oral Surgeon, Anesthesiologist,
CRNA, Other (specify)
Page 5 of 10
32. Do you possess any ALS certifications? YES NO If yes, specify: __________________________________________
33. Which of the following emergency treatment items do you have available?
____ Oral airway ____ Ambu bag ____ Endotracheal tubes/scopes
____ Oxygen ____ Emergency drugs ____ None available
34. Provide the approximate percentage of your practice in the following:
Cosmetic Dentistry
Bonding ____%
Enamel Shaping ____%
Full Mouth Restoration ____%
Veneers ____%
Whitening with Lasers ____%
Other Procedures ____%
_________________________
Non-Dental Cosmetic Procedures
(Botox, Collagen, fillers, etc.) ____%
Endodontics
Single Rooted ____%
Multi Rooted ____%
Sargenti Root Canal Method ____%
Extractions
Simple Extractions ____%
Impacted - Soft Tissue ____%
Impacted - Partial Bony ____%
Impacted - Full Bony ____%
Implants
Restoration ____%
Placement ____%
Oral Pathology ____%
Oral Radiology ____%
Orthodontics ____%
Pediatric Dentistry ____%
Periodontics ____%
Prosthodontics
Fixed ____%
Removable ____%
Non-Surgical Sleep Apnea Therapy ____%
Surgery
Facial – Elective Cosmetic ____%
Head and Neck ____%
Oral/Maxillofacial ____%
Outside oral/maxillofacial region ____%
Orthognathic Procedures ____%
Bone Grafting ____%
Sleep Apnea Surgery ____%
Microneurosurgical Procedures ____%
TMJ
Non-Surgical ____%
Surgical ____%
TOTAL 100%
35. If you have performed any implant procedures within the last year, please answer the following:
I have not performed any implant procedures within the last year: _____(initial)
1. Osseointegration only _____# procedures
2. Endosteal - Ramus Frame _____# procedures
3. Endosteal - Other _____# procedures
4. Subperiosteal (above bone but beneath gum) _____# procedures
5. Transosseus (penetrate entire jaw) _____# procedures
6. Other ________________________________________ _____# procedures
36. Do you perform sinus lifts or other surgical procedures in conjunction with implant procedures?
If yes, how many are performed annually? ______
YES NO
37. If you perform sleep apnea therapy, do you treat only after referral from a physician?
YES NO
PRIOR POLICY AND LOSS INFORMATION – Provide details for all “YES” answers on Page 7
38. Has your dental or narcotics license ever been limited, suspended, revoked, denied, or
investigated by any licensing board or regulatory agency?
YES NO
39. Has your board certification or membership in any medical society or association ever been
refused, suspended, revoked, or voluntarily surrendered?
YES NO
Page 6 of 10
40. Have your hospital privileges ever been suspended, restricted, denied, placed in probationary
status, or revoked?
YES NO
41. Have you ever been charged with, or convicted of a crime other than minor traffic violations?
YES NO
42. Have you ever been diagnosed or treated for alcoholism, drug addiction, any chemical
dependency, or mental or chronic physical illness?
YES NO
43. Has any fee or professional relations complaints been registered against you with your dental
association, hospital, or a state licensing authority?
YES NO
44. Provide the following information pertaining to your past 5 years of professional liability insurance coverage:
Carrier
Policy Period
Policy Limits
Deductible
Retro Date
45. Have you ever practiced without professional liability insurance?
YES NO
46. Do you have professional liability insurance for work you do elsewhere?
YES NO
47. Have you ever had any insurance company decline, cancel, rescind, or non-renew any professional
liability insurance policy?
YES NO
48. Have you ever been involved in any professional liability claim or suit, either directly or indirectly?
YES NO
49. 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
50. Are you aware of any request for medical records by a patient or his/her attorney which might
result in a claim?
YES NO
51. Are you aware of any acts, errors, omissions, or circumstances that might reasonably lead to a
claim or suit, even if you believe them to be without merit? If yes, please complete a supplemental
claims form for each circumstance.
YES NO
Page 7 of 10
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.
• I have no known losses or claims that have not been reported to my prior insurance carrier or any other source
from which payment might be made;
• I have no knowledge 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;
• I have no knowledge of any request for medical records by a patient or their attorney which might result in a
claim;
• I have no knowledge or information relating to service or services on a Board which might result in a claim; and
• I have 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 confirms the above statements
STATEMENT OF NO KNOWN CLAIMS OR CIRCUMSTANCES
Page 8 of 10
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.
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.
FRAUD WARNING
Page 9 of 10
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 facts.
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 (Print Name):
________________________________________
Title:
_________________
Applicant’s Signature:
________________________________________
Date:
_________________
Agent / Broker Name:
_____________________________________________________________________
click to sign
signature
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Page 10 of 10
SUPPLEMENTAL CLAIMS INFORMATION
If reporting more than one claim, please photocopy this form 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/dated.
Name of Patient/Claimant: ____________________________________________
Age: ________
Sex: ________
Date of Alleged Incident: __________________________
Date Reported to Insurance Company: __________________
Name of Insurance Company: _________________________________________________________________________
Additional Defendant(s): ______________________________________________________________________________
Allegation: _________________________________________________________________________________________
__________________________________________________________________________________________________
Description of Medical Services Rendered to Patient: ______________________________________________________
_________________________________________________________________________________________________
_
_
_________________________________________________________________________________________________
Present Condition of Patient: __________________________________________________________________________
Status of Claim:
Dismissed (no payment made to claimant)
Defense Verdict
Plaintiff Verdict
Total Awarded: $ _____________
Amount Paid on Your Behalf: $ ____________
Settlement
Total Awarded: $ _____________
Amount Paid on Your Behalf: $ ____________
Open
Loss Reserves: $ ______________
Plaintiff’s Demand: $ ____________________
To your knowledge, was any settlement paid by another party involved?
YES NO
Explain in detail what action(s) you have taken to prevent recurrence of this type of claim: ________________________
_________________________________________________________________________________________________
_
_
_________________________________________________________________________________________________
Applicant’s Signature: ______________________________________________
Applicant (Print Name): _____________________________________________
Date: _________________
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Dentists And Oral Surgeons New Business Application (Kinsale Insurance)

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Completed 16 July 2020

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