Fillable HC PHYSICIAN RENEWAL APPLICATION

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HC PHYSICIAN RENEWAL APPLICATION

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The HC PHYSICIAN RENEWAL APPLICATION form is 8 pages long and contains:

  • 2 signatures
  • 216 check-boxes
  • 159 other fields

Country of origin: US
File type: PDF

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Page 1 of 8
PHYSICIANS & SURGEONS RENEWAL 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 renewal 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 Curriculum Vitae and letterhead IF CHANGED IN THE PAST 12 MONTHS.
- Current loss runs from a prior insurance company, IF ANY OF THE FOLLOWING APPLIES:
• There was an open claim, suit or incident pending with a prior insurance company;
• An Extended Reporting Period (ERP) Endorsement was purchased from a prior insurance carrier
within the past 5 years;
• Coverage was written on an occurrence basis by the insurance company within the past 5 years.
- A Claim Supplemental Form or comprehensive narrative on your letterhead must be
completed for each claim resolved/closed or a new claim made, incident surfacing and/or
suit brought against you IN THE PAST 12 MONTHS that has not already been reported to
Kinsale Insurance Company.
PERSONAL INFORMATION
Applicant’s Name: _________________________________________________________ MD DO
Business Entity Name:_______________________________________________________________________________
Practice Address: ___________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Mailing Address: ___________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 8
Provide the following information for all states in which you are license to practice:
State
% of Practice
License#
Active
Inactive
Temporary
Pending
Risk Management Contact Name:
Risk Management Contact E-mail:
PRACTICE SPECIALTY
1. Current Practice Specialty: % of Practice:
Subspecialty: % of Practice:
2. Do you limit your practice to the above Specialty and/or Sub-Specialty? YES NO
If NO, please explain:
3. Have you added or discontinued procedures which are considered to be outside of, or not YES NO
usual to the above practice specialty, or are experimental in nature within the past year, or
do you anticipate doing so in the near future? If YES, please list procedures/services and note dates of change(s):
4. Have you changed your medical specialty within the past year or do you anticipate doing YES NO
so in the near future? If YES, please explain:
5. Indicate number of CME hours you have completed in past two years:
OFFICE STAFF
6. Do you employ, contract with, or supervise any physicians or surgeons? YES NO
If YES, provide the names and attach certificate of insurance for each:
7. Do you share office space or have an expense sharing arrangement with any other physician YES NO
or surgeon other than those named above? Please provide details on page 5.
8. Do you employ, contract with, or supervise any physicians or surgeons? YES NO
If YES, provide the names and attach certificate of insurance for each:
Page 3 of 8
9. 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
SPECIFICS OF PRACTICE/PROCEDURES
10. Average Weekly Practice Hours:
___________
11. Average Weekly Patient Encounters:
___________
12. Percentage of Practice that is Locum
Tenens Work:
___________%
13. 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? Yes No If YES, provide copy of the COI.
YES NO
14. 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
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
Page 4 of 8
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
15. In the past 12 months:
a. Has any State/Medical Board refused you a medical license? YES NO
b. Has any State/Medical Board restricted, suspended or revoked your medical license? YES NO
c. Has any State/Medical Board imposed a fine or any other obligation? YES NO
d. Has any State/Medical Board issued a letter of guidance or public reprimand? YES NO
e. Have you voluntarily surrendered a medical license? YES NO
f. Has any State/Medical Board placed you on probation or restricted your practice? YES NO
g. Is your medical license currently under investigation for any reason in any state? YES NO
h. Has your Narcotics/DEA license been surrendered/refused/suspended/revoked YES NO
(voluntarily or otherwise)?
i. Has there been any professional conduct or fee complaint filed against you with any YES NO
Specialty, National, State or County Medical Society, other Professional Association or any licensing or
regulatory authority?
If YES to any of the above, describe the circumstances, outcome, dates on Page 6 and attach copies of any relevant
documents.
16. In the past 12 months:
a. Have you become American Board Certified or Eligible? YES NO
b. Has your Board Certification or membership in any medical association/society YES NO
been refused, suspended, revoked or voluntarily surrendered?
Page 5 of 8
17. In the past 12 months:
a. Have you been evaluated, treated, or recommended for treatment of alcohol, YES NO
narcotics, or any other substance abuse, sexual addiction, or mental illness?
b. Have you been diagnosed with, or treated for, a chronic physical illness and/or disability? YES NO
c. Have you become aware of any physical illness, mental illness and/or disability which YES NO
affects, or could affect, your ability to practice medicine now or anytime in the future?
IF YES to any of the above, describe circumstances, outcome, dates and attach copies of any relevant
documents (including a letter from your treating physician addressing your state of health and whether
such condition could adversely affect your ability to practice medicine).
18. IN THE PAST 12 MONTHS, have you been charged with or convicted of a felony or YES NO
misdemeanor for anything other than a minor traffic violation? IF YES, describe circumstances,
outcome, dates and attach any relevant documents.
19. IN THE PAST 12 MONTHS, have your hospital privileges been suspended, denied, YES NO
revoked, restricted, or otherwise sanctioned? IF YES, describe circumstances, outcome, dates
and attach any relevant documents.
20. Are you aware of any request for medical records by a patient or his/her attorney which might
result in a claim? If YES, please complete Supplemental Claims Information on Page 8.
YES NO
21. 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?
If YES, describe circumstances, outcome, dates and attach any relevant
documents.
YES NO
22. 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
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
Page 7 of 8
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.
My signature below confirms the above statements
CONSENT, WARRANTY, REPRESENTATIONS and ACKNOWLEDGMENT of UNDERSTANDING FRAUD WARNING
Any person who knowingly, and with the intent to defraud any insurance company or other person, includes any false or
misleading information in an application for insurance or statement of claim commits a fraudulent insurance act, which
is a crime and subjects the person to criminal and civil penalties and denial of insurance benefits.
The applicant declares that the information contained herein is accurate and that no material facts have been
suppressed. The applicant understands and acknowledges that the information contained in the application is deemed
material and that any policy issued by the Company is done so in reliance upon the truth of the applicant’s
representations. The applicant understands that incorrect information could void coverage.
Signature: ___________________________________________________________ Date:_____________________
Printed Name:________________________________________________________
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Page 8 of 8
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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HC PHYSICIAN RENEWAL APPLICATION

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Completed 2 July 2020

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