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INDIVIDUAL PODIATRISTS APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE IMPORTANT (Risk Placement Services, Inc.)

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Preferred Professional RRG
PPRRG CPP-100 (08/15) Podiatry Preferred Page 1 of 7
INDIVIDUAL PODIATRISTS
APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE
IMPORTANT INSTRUCTIONS - PLEASE READ CAREFULLY
1. PLEASE MAKE SURE ALL QUESTIONS ARE ANSWERED IN FULL.
Incomplete or missing answers will cause delays in processing and may cause coverage to be declined.
2. IF YOU HAVE HAD CLAIMS OR SUITS FILED AGAINST YOU OR HAVE REPORTED INCIDENTS TO YOUR
CURRENT INSURANCE COMPANY, please make certain you have completed the claim information report on page
8 for each claim, suit, or incident.
3. SIGNATURES ARE REQUIRED. The policy application and claim information report form must be signed (Pages 7
and 8).
4. PLEASE ATTACH A COPY OF YOUR CURRENT DECLARATIONS PAGE SHOWING RETROACTIVE DATE.
We are aware of the urgent concern of many health care providers regarding their insurance renewal date.
However, applicants must meet the underwriting standards of Preferred Professional Risk Retention
Group before coverage will be provided. Qualified applicants who meet our underwriting standards can
receive an effective date as early as the date submitted to us, if so requested.
FOR ASSISTANCE, PROVIDERS MAY CALL OUR OFFICE
Toll: (800) 397-9697, ext. 2629
Main: (719) 528-8200
Direct: (719) 219-2629
FAX: (719) 528-8323
RPS Healthcare
1975 Research Pkwy, Suite 230
Colorado Springs, Colorado 80920
Notice: “This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the
insurance laws and regulations of your state. State insurance insolvency guaranty funds are not available for your
risk retention group.”
PPRRG CPP-100 (08/15) Podiatry Preferred Page 2 of 7
INDIVIDUAL PODIATRISTS
APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE
CLAIMS MADE BASIS
(Please type or print)
I. GENERAL INFORMATION
1. Name:
Last Middle Initial First
2. DBA:
3. Website:
4. Date of Birth: 5. Social Security #:
6. Phone: 7. Fax: 8. Email:
9. Primary Practice Address:
Street
City
County
State
Zip
10. Contact Person: 11. Title:
12. Contact Email:
13. Billing Address:
(If different than above)
Street
City
County
State
Zip
II. EDUCATIONAL INFORMATION
14. Podiatric Medical School: 15. Year Graduated:
16. Degree:
17. Date you began practice:
(after license & residency)
18. I completed an Internship
Residency
or
Preceptorship
# of Years:
Year Completed:
Name of Hospital where completed:
19. Memberships, Licenses, and Affiliations:
a) Are you Board Certified / Eligible? Yes No Completion Date:
b) Please check the professional organizations to which you belong:
Am. College of Foot & Ankle Orthopedics & Medicine (ACF) Am. Board of Podiatric Surgery (ABPS)
Am. Podiatric Medical Association (APMA) Academy of Ambulatory Foot Surgery (AAFS)
Am. College of Foot Surgeons (ACFS) Other:
20. Podiatric/Medical License Number(s) State Expiration Date(s)
21. Narcotic/Drug License Number(s) State(s) Expiration Date(s)
22. Have you participated in any risk management forums during the past year? Yes No
If YES, provide information below for possible credit.
Date: Co. Sponsor: Name of Seminar/Self Study:
Type of Risk Management:
Self Study ½ Day Seminar Full Day Seminar ELM Other
PPRRG CPP-100 (08/15) Podiatry Preferred Page 3 of 7
III. PRACTICE LOCATIONS
23. Do you practice as:
Solo Unincorporated Solo Incorporated Partner in a Partnership Independent Contractor
Employed Podiatrist in a Corporation not Owned by You Other
24. Do you have ownership interest in any Professional Corporation (PC), Professional Association (PA) or Limited Liability Corp (LLC)?
Yes No PC/PA/LLC Name: Tax ID:
Would you like to add this entity as:
Separate Limit Liability If Yes, complete and submit Corporation Application
Shared Limit of Liability
If Yes, give legal name of corporation(s):
Practice website address (URL):
25. In what state do you do the majority of your practice?
a) Do you practice in any other state?
Yes No
If Yes, name of state(s): Percent of Practice: %
26. Have you moved your practice within the last two years?
Yes No
If Yes, please provide the previous address of your practice.
27. List all locations (or name of hospital) where you currently practice or have practiced in the last ten years (beginning with current
practice):
Practice Location (or name of Hospital) City State Dates
# of Admissions
(consultations or
procedures)
Percentage
(if current
practice)
%
%
%
%
Note: Certificates of insurance are provided to all hospitals, at which you indicate privileges are held. If you do not wish to have a
certificate sent to a particular hospital, please indicate.
28. Average number of hours you practice per week:
Note: Hours practiced include consulting, paperwork, lab time, and hospital hours.
Have your hours changed in the past five years? Yes No If Yes, what were your previous hours?
III. PRACTICE LOCATIONS (CONT)
29. If you are employed by others, or perform services on behalf of others as an
independent contractor, list the names of those other persons or entities :
Employment Status
Employee Independent Contractor
Employee Independent Contractor
30. Is your practice office or hospital based? (Please select one) Office Hospital
If Office based, what percentage of your practice is conducted in your office? %
IV. CURRENT PRACTICE
31. What percent of your total practice involves:
A. Local Anesthesia: %
B. General Anesthesia: %
*Includes IV Conscious Sedation
Practices using General Anesthesia must complete and sign the anesthesia supplement on page 9.
PPRRG CPP-100 (08/15) Podiatry Preferred Page 4 of 7
32. How many of the following surgeries do you perform a 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):
33. What percent of your patient load involves diabetic patients? 0-15% 16-30% 31-50% 51-70% 71-100%
34. Do you obtain:
Written informed consent OR Verbal informed surgical consent from your patients
V. COVERAGE INFORMATION
35. Are you currently insured?
Yes Insurance Company: Expiration Date:
Years with company: Limits of Liability:
No
If you are currently not insured and are not in your first year of practice, please attach a summary that includes, 1) the
last date of coverage and insurance company; 2) reason why you are currently not insured; and 3) why you need to
secure coverage now.
36. Proposed Effective Date: 37. Retroactive Date:
Please Note: If you are currently not insured, the proposed effective date cannot be backdated and retroactive coverage is not available.
**Attach copy of Declarations Page from your current professional liability insurance company showing retroactive date**
38. Limits of Liability Desired (per claim/aggregate) Note: Some limits are not available in certain states.
$100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,500,000
$1,000,000/$1,000,000 $1,000,000/$3,000,000 $2,000,000/$4,000,000 Other $
VI. PRACTICE HISTORY – PLESE EXPLAIN ALL YES ANSWERS (BELOW) IN THE REMARKS SECTION
39. Has any insurer, to whom you applied for medical professional liability or related coverage, canceled, declined,
rescinded or modified coverage, or refused renewal, excluding insurance company withdrawal?
(e.g. reduced limits, assigned a deductible, restricted coverage, surcharged rates)
Missouri applicants DO NOT answer this question
Yes No
40. Has anyone ever filed a complaint of any kind against you with your medical society or association? Yes No
41. Has any hospital or other institution reduced, revoked, restricted or suspended your privileges? Yes No
42. Have you voluntarily withdrawn or resigned from any hospital privileges in lieu of disciplinary action? Yes No
43. Have you ever been under punitive or disciplinary observation, preceptorship, or sponsorship in a hospital? Yes No
44. Has any governmental or licensing agency ever investigated, suspended, revoked, placed on probation, or taken any
other action against either your narcotics license or your license(s) to practice podiatry?
Yes No
It is not the intent of the Coverys/PPIC policy to cover known patient injuries. If you are requesting Prior
Acts coverage for your professional liability exposure, we must have confirmation that you have informed
your current Professional Liability carrier of any incidents or circumstances that could lead to a claim that
may be made against you.
Your signature on the application form indicates that you have complied with the above provisions.
45. Have you ever been notified of your involvement in a malpractice claim, suit, or “incident” either directly or indirectly? Yes No
46. Are you aware of any incident that could lead to a malpractice claim? Yes No
47. Do you have or have you had any physical disability or injury, personal health problems, including alcoholism,
narcotics addition or mental illness which affects your ability to practice podiatry?
Yes No
48. Have you ever had a complaint or claim brought against you for sexual misconduct? Yes No
PPRRG CPP-100 (08/15) Podiatry Preferred Page 5 of 7
VII. REMARKS SECTION
VIII. FRAUD STATEMENT
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 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
five thousand dollars and the stated value of the claim for each such violation)*. *Applies in New York only
DECLARATION AND CERTIFICATION:
BY SIGNING THIS APPLICATION, THE APPLICANT REPRESENTS TO THE COMPANY THAT ALL STATEMENTS MADE IN THIS
APPLICATION ABOUT THE APPLICANT AND ITS OPERATIONS ARE TRUE AND COMPLETE, AND THAT NO MATERIAL FACTS
HAVE BEEN MISSTATED IN THIS APPLICATION OR CONCEALED. THE APPLICANT HEREBY AUTHORIZES THE RELEASE OF
CLAIMS INFORMATION FROM ANY PRIOR INSURERS TO THE COMPANY. COMPLETION OF THIS FORM DOES NOT BIND
COVERAGE. THE APPLICANT’S ACCEPTANCE OF THE COMPANY’S QUOTATION IS REQUIRED BEFORE THE APPLICANT MAY
BE BOUND AND A POLICY ISSUED.
THE APPLICANT AGREES THAT IF AFTER THE DATE OF THIS APPLICATION, ANY INCIDENT, OCCURRENCE, EVENT OR OTHER
CIRCUMSTANCE SHOULD RENDER ANY OF THE INFORMATION CONTAINED IN THIS APPLICATION OR ANY OTHER
DOCUMENTS SUBMITTED IN CONNECTION WITH THE UNDERWRITING OF THIS APPLICATION INACCURATE OR INCOMPLETE,
THEN THE APPLICANT SHALL NOTIFY THE COMPANY OF SUCH INCIDENT, OCCURRENCE, EVENT OR CIRCUMSTANCE AND
SHALL PROVIDE THE COMPANY WITH INFORMATION THAT WOULD COMPLETE, UPDATE OR CORRECT SUCH INFORMATION.
ANY OUTSTANDING QUOTATIONS OR BINDERS MAY BE MODIFIED OR WITHDRAWN AT THE SOLE DISCRETION OF THE
COMPANY.
THE APPLICANT AGREES TO COOPERATE WITH THE COMPANY IN IMPLEMENTING AN ONGOING PROGRAM OF LOSS-
CONTROL AND WILL ALLOW THE COMPANY TO REVIEW AND MONITOR SUCH PROGRAMS THAT THE APPLICANT
UNDERTAKES IN MANAGING ITS MEDICAL PROFESSIONAL EXPOSURES.

Signature of Applicant Signature of Broker/Agent
Title Date
Date
Signed by Licensed Resident Agent
(Where Required By Law)
COMPLETION OF THIS FORM NEITHER BINDS COVERAGE NOR GUARANTEES A POLICY WILL BE ISSUED.
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PPRRG CPP-100 (08/15) Podiatry Preferred Page 6 of 7
PODIATRIC CLAIM OR INCIDENT REPORT SUPPLEMENT
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.
1.
Name:
First Middle Initial Last
2. Claimant Name:
3. Type of Claim: Incident Claim
4. Name of Insurance Company:
5. Date Reported to Insurance Company:
6. Date of Incident/Claim:
7. Status of incident/claim: Suit threatened, no action taken
Court outcome in YOUR favor Unresolved/Open
Suit filed but dropped by claimant
Court outcome in PLAINTIFF favor
Awaiting mediation
Summary judgment in your favor Directed Verdict Awaiting court action
If closed,
Settled Trial If settled, did you want to settle? Yes No
Date Closed:
Expense Paid: $
Indemnity Paid: $
If open,
Reserve Amount: $
8. Allegations/Circumstances:
9. Treatment Provided:
10. Present condition of claimant:
11. Additional Defendants:
12. What action(s) have you taken to prevent recurrence of this type of claim?
13. Did you in any way alter, embellish, delete, change or destroy any medical records or were allegations made that you
did?
Yes No
I understand information submitted herein becomes a part of my Professional Liability Application and is subject to the same
conditions.

Signature of Applicant Date
Printed Name
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PPRRG CPP-100 (08/15) Podiatry Preferred Page 7 of 7
PODIATRIC ANESTHESIA SUPPLEMENT
I. APPLICANT INFORMATION
1. Name:
First Middle Initial Last
II. PRACTICE ACTIVITIES
2. General Anesthesia
Please indicate who administers general anesthesia:
I do MD/DO Anesthesiologist Nurse Anesthetist/CRNA
Other (please explain):
• Where is general anesthesia performed?
In office Hospital Licensed Surgical Center
Other (please explain):
3. How often do you treat patients under general anesthesia:
4. If general anesthesia is performed at a location other than a hospital, how often do you and your staff participate in simulated emergency
training?
Every 3 months Every 6 months Every 12 months
Other (please explain):
5. Are you or the individual administering the general anesthesia certified in one or more of the following?.......................
Yes No
If yes, please indicate:
CPR ACLS ATLS PALS
6. Do you use the following equipment?............................................................................................................................... Yes No
If yes, please check all that apply:
Autoclave Pulse Oximeter
Full Face Mask Resuscitator CO2 Monitor
Endotracheal Tubes (adult/child size Internal/External Temperature Monitor
Laryngoscope Portable Suction
Direct Current Defibrillator Capnography
Tracheostomy/Coniotomy Equipment Auxiliary Lighting
Sphygmomanometer/Stethoscope Emergency Pharmaceutical Kit
Electrocardiographic monitoring Equipment Fail safe mechanisms on anesthesia machines
7. Do all anesthesia providers who are providing anesthesia services to your patients:
Have a minimum of two years of anesthesia residency training?
Yes No
Have professional liability insurance limits equal to or greater than your policy limits?
Yes No
If anesthesia is being provided by a CRNA, are they supervised on site by a doctor with a minimum two years or
greater residency in anesthesia?
Yes No
I understand information submitted herein becomes a part of my Professional Liability Application and is subject to the same
conditions.
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Signature of Applicant Date
Printed Name
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