Fillable HC PHYSICIAN AND SURGEON APP-1

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HC PHYSICIAN AND SURGEON APP-1

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Page 1 of 11
PHYSICIANS & 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
- 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: _________________________________________________________ MD DO
Social Security Number: ________ - ______ - ________
Date of Birth _____ / _____ / ________
Practice Address: ___________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Mailing Address: ___________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Are you a U.S. Citizen? Yes No If no, indicated status and date of entry _________________________________
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
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 11
PRACTICE SPECIALTY AND EDUCATION
1. List all locations and dates where you have practiced in the last 10 years.
Practice Name
City/State
From
To
2. Current Practice
Specialty
________________________________
% of Practice: _________
Subspecialty
________________________________
% of Practice: _________
3. Board Certification:
Board Certified
Name of Board(s):_____________________________________________
_____________________________________________
Board Eligible
Date of Exam: ____ / ____ / ______
Board Qualified
If Board Eligible for Over Five Years, But Not Board Certified, Then Please Explain:
______________________________________________________________________________
______________________________________________________________________________
4. Complete the following:
Institution
Location
Degree/Specialty
Completed?
Medical School
YES NO
Internship
YES NO
Residency
YES NO
Fellowship
YES NO
5. Date you began practicing medicine _______________
6. Indicate number of CME hours you have completed in past two years: _______
7. Are you ACLS certified?
YES NO
8. Are you ATLS certified?
YES NO
PRACTICE INFORMATION
8. Applicant is an:
Individual
Corporation
LLC
Partnership
Employed Physician: By Whom: ____________________________
Contracted Physician: By Whom: ____________________________
Practice is a: Solo Practice Group Practice
Page 3 of 11
9. Entity Name:____________________________________________________ Applicant’s % Ownership: ______%
10. Risk Management Contact Name:
11. Risk Management Contact E-mail:
12. Are you requesting that the entity be named on your policy?
If yes, please forward articles of incorporation.
YES NO
OFFICE STAFF
13. Do you employ, contract with, or supervise any physicians or surgeons? If yes, provide the names and
attach certificate of insurance for each:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
YES NO
14. Do you share office space or have an expense sharing arrangement with any other physician or
surgeon other than those named above?
Please provide details on page 7.
YES NO
15. Please complete the staff table.
TYPE
Number Employed
Coverage
Desired?
Number
Contracted
Insured
Elsewhere?
Midwife*
YES NO
YES NO
CRNA*
YES NO
YES NO
Nurse Practitioner
YES NO
YES NO
Physician Assistant
YES NO
YES NO
Surgeon Assistant
YES NO
YES NO
Optometrist
YES NO
YES NO
Lab Technician
YES NO
YES NO
Pharmacists
YES NO
YES NO
Nurse (RN or LPN)
YES NO
YES NO
X-Ray Technician
YES NO
YES NO
Physical Therapist
YES NO
YES NO
Other:
YES NO
YES NO
Other:
YES NO
YES NO
* Separate application must be submitted
SPECIFICS OF PRACTICE/PROCEDURES
16. Average Weekly Practice Hours:
___________
17. Average Weekly Patient Encounters:
___________
18. Percentage of Locum Tenens Work:
___________%
19. Do you work for any Locum Tenens companies as an employee or independent contractor?
If yes, indicate number of hours worked each month:____ AND does the Locum Tenens company provide you with
Professional Liability insurance? No: Yes: If yes, provide copy of the COI.
YES NO
20. Have there been any changes in your specialty or practice activities within the past 10 years?
If yes, explain:
YES NO
Page 4 of 11
21. Do you perform any procedure not routinely performed by others practicing in your specialty
or subspecialty? If yes, explain:
YES NO
22.
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
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
23. Are you currently or ever been a hospital chief of staff or head of any hospital department?
If yes, explain:________________________________________________________________________________
YES NO
24. Do you or any entity named in this application own, operate, administer, maintain a
relationship with, or supervise any overnight bed and board facility, urgent care facility,
commercial laboratory, urgent care center, surgicenter, abortion clinic, walk-in clinic, or
birthing center.
If yes, explain on page 7.
YES NO
25. Do you serve as a medical director of a nursing home, clinic, commercial enterprise, or any
other organization? If yes, explain on page 7 and attach a copy of any contract or agreement describing the
position.
YES NO
26. Do you work in an Emergency Room, other than to maintain privileges?
(If yes, provide the average number of ER hours worked per month) ________
YES NO
27. Are you employed full-time or part-time by the federal, state, or local government, or are you
on active military duty? If yes, please explain: _____________________________________________________
_______________________________________________________________________________________________
YES NO
28. Do you treat patients in a nursing home, correctional facility or similar care facility?
If yes, percentage of practice ______%
Name(s) of Facilities:
__________________________________________________________
__________________________________________________________
__________________________________________________________
YES NO
29. Are you a sports team physician or health care provider?
If yes: High school College Professional Other_______________
YES NO
30. 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
Page 5 of 11
31. Do you practice any forms of Alternative Medicine including but not limited to Ayurvedic
Medicine, Chinese Medicine, Homeopathic Medicine, Chiropractic Medicine, Holistic Medicine,
or Naturopathic Medicine?
If yes please explain on page 7.
YES NO
32.
Are you engaged in any moonlighting activities?
(If yes, are you requesting coverage for these activities?
NO YES and describe)_______________________________________________________________________
______________________________________________________________________________________________
YES NO
33. If you are not a radiologist, do you read your own x-rays?
(If yes, indicate how many hours before they are subsequently read by a radiologist) _______
YES NO
34. Do you read or interpret films, slides, or specimens of patients who reside in states other than
your indicated practice states? If yes, please explain on page 7 indicating which states and how much each
represented as a % of your practice.
YES NO
35. 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 medical services?
If yes please explain on page 7.
YES NO
36. Do you prescribe drugs or provide diagnosis via the internet?
If yes please explain on page 7.
YES NO
37. Do you perform surgery, other than incision of boils and superficial abscesses or suturing and
superficial fascia?
YES NO
38. Do you perform surgical procedures using nurse anesthetists to administer anesthesia who are
not directed by or responsible to an anesthesiologist?
YES NO
39. Do you perform surgical procedures at a same-day surgery center other than your own office?
YES NO
40. Do you perform surgery in your office or private suite using anesthesia other than local or
topical? If yes, please complete the following:
YES NO
Procedures
Anesthetic or Parenteral Sedation
Emergency Equipment and/or Procedures in Place
41. Check all Procedures/Treatments that you perform:
Abortions
Intensive Care for Adults
Acupuncture
Joint Replacement Surgery
Adenoidectomy
Laparoscopy
Amputations
Mastoidectomy
Anesthesia (circle: OB or non-OB)
MOHS Micrographic Surgery
Angiography
Needle Biopsy
Angioplasty
Office Gynecology
Assist in Surgery (circle: own or other patients)
Obstetrics
Arterial Catheterization
Prenatal Care
Arteriography
1
st
Trimester
Bariatric Surgeries: (Supplement Required)
2
nd
Trimester
Cardiac Catheterization
3
rd
Trimester
Page 6 of 11
Cervical Biopsy
Normal Deliveries (indicate # annually____)
Chelation Therapy (circle: cardiac care or heavy metal)
VBAC Deliveries (indicate # annually____)
Chemonucleolysis
High risk patient (indicate # annually____)
Chemotherapy
Open Reduction of Fractures
Clinical Trials
Organ Transplants
Closed Reduction Fractures
Orthopedic Surgery Excluding Spine
Cholecystectomies
Orthopedic Surgery Including Spine
Colonoscopy
Osteopathic Manipulative Medicine
Complex Flaps and Grafts
Pain Management
Cosmetic Procedures
Medication Only
Breast Implants/Augmentations/Reductions
Procedures: (Supplement Required)
Botox Injection
Pedicle Screw Insertion
Chemical Peels
Penile Augmentation
Chemobrasion
Penile Prosthetic Implants
Collagen Injection
Pericardiocentesis
Dermabrasion
Permanent Pacemaker Insertion
Fat Transfer
Pneumoencephalography
Hair Transplant
Prolotherapy
Liposuction
Prostatectomy
Lipodissolve
Radial Keratotomy
Facial Plastic Surgery (circle Elective or Reconstructive)
Radiopaque Dye Injections
Mesotherapy
Refractive Surgery (circle LASIK, PRK, PTK, AK, ICR)
Microdermabrasion
Thoracic Surgery
Sclerotherapy
Transgender Surgery or Hormonal Gender Coversion
Silicone Injection
Tubal Ligation
Laser Hair Removal
Vasectomy
Rhinoplasty
Vertebroplasty
Other Laser Procedure (specify:____________)
Other:_______________________________
Other Cosmetic Procedure
Other:_______________________________
Dilaton and Curettage
Echocardiography
Electroshock Therapy
None of the above procedures apply to my practice.
Please initial _________
Endoscopic Procedures
Hernioplasty
Hemorrhoidectomies
Hyperberic Chamber Treatments
Interphalangeal Joint Surgery
Intensive Care for Newborns
PRIOR POLICY AND LOSS INFORMATION – Questions 42-56 PROVIDE DETAILS FOR ALL “YES” ANSWERS
42. Has your medical or narcotics license ever been limited, suspended, revoked, denied, or
investigated by any licensing board or regulatory agency?
YES NO
43. Has your board certification or membership in any medical society or association ever been
refused, suspended, revoked, or voluntarily surrendered?
YES NO
44. Have your hospital privileges ever been suspended, restricted, denied, placed in probationary
status, or revoked?
YES NO
45. Have you ever been charged with, or convicted of a crime other than minor traffic violations?
YES NO
46. Have you ever been diagnosed or treated for alcoholism, drug addiction, any chemical
dependency, or mental or chronic physical illness?
YES NO
47. Has any fee or professional relations complaints been registered against you with your medical
association, hospital, or a state licensing authority?
YES NO
Page 7 of 11
Provide details for all “yes” answers to questions 42-56 on page 7 or attach additional pages as needed
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
48. Provide the following information pertaining to your past 5 years of professional liability insurance coverage:
Carrier
Policy Period
Policy Limits
Deductible
Claims Made or
Occurrence
Retro Date
49. Have you ever practiced without professional liability insurance?
YES NO
50. Do you have professional liability insurance for work you do elsewhere?
If yes, please explain on page 7.
YES NO
51. Have you ever had any insurance company decline, cancel, rescind, or non-renew any
professional liability insurance policy?
YES NO
52. Have you ever been involved in any professional liability claim or suit, either directly or
indirectly?
YES NO
53. 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
54. Are you aware of any request for medical records by a patient or his/her attorney which might
result in a claim?
YES NO
55. 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
56. 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 8 of 11
$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
STATEMENT OF NO KNOWN CLAIMS or CIRCUMSTANCES
• 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.
Page 9 of 11
MY SIGNATURE ON PAGE 9 CONFIRMS THE ABOVE STATEMENTS UNLESS OTHERWISE NOTED
FRAUD WARNING
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.
Page 10 of 11
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 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:
_____________________________________
Title:
________________________________
FEIN #:
_____________________________________
Applicant’s Signature:
___________________________
Date:
________________________________
Agent / Broker Name:
_____________________________________________________________________
Page 11 of 11
SUPPLEMENTAL CLAIMS INFORMATION
If reporting more than one claim, then 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.
Name of Patient: Age:______ Sex:_______
Date reported to insurance company:
Name of insurance company:
Date of incident and your treatment:
Allegations:
Additional Defendants:
What is the present condition of the patient?
Status of Claim
___Suit threatened, no action taken Court outcome in your favor: Unresolved/Open
___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:
a. Date claim paid:___________ ___Jury verdict $__________________
b. Amount paid:$____________ ___Directed verdict
c. 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 Yes No
(i.e., your P.A., P.C., partners, employees, etc.)?
Explain in detail what action(s) you have taken to prevent recurrence of this type of claim:
Signature: Date:
Printed Name:
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Completed 2 July 2020

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