MP 4004a 01 07
Copyright, American Alternative Insurance Corporation, 2006
Page 2 of 2
13. Do you a
dmit patients to the hospital? Yes___ No___ Discharge patients from the hospital? Yes___ No___
14. Have you ever had a malpractice claim or suit filed against you? Yes___ No___
(If yes, please attach detailed claim information and a detailed description for each claim or allegation.)
15. Have all known potential claims, incidents or suits, if any, been reported to your present carrier? Yes___No___
16. Have you ever had your medical license revoked, suspended, restricted or placed on probation? Yes___No___
17. Has your license to practice medicine or medical staff privileges or appointment to a hospital ever been suspended,
voluntarily withdrawn, reduced, withheld, denied, revoked or subjected to any disciplinary action? Yes___No___
(If yes, describe circumstances.)_______________________________________________________________
_________________________________________________________________________________________
18. Have you ever been the subject of an investigation, disciplinary proceeding or reprimand? Yes___ No___
19. Have you ever been convicted of a crime or felony? Yes___ No___
20. Have you ever been treated for alcoholism or drug addiction? Yes___ No___
21. Provide information on your in-force malpractice insurance. (if none exists, please indicate “none”)
a. Insurance Company Name ________________________________Expiration date _________________
b. Limits of Liability $______________________________________Policy # ______________________
c. Does your malpractice policy cover you while performing work for the agency/organization? Yes___
No___
NOTICE TO APPLICANT – PLEASE READ CAREFULLY
FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED, AS AUTHORIZED AGENT FOR ALL
PERSONS AND ENTITIES PROPOSED FOR THIS INSURANCE, DECLARES THAT TO THE BEST OF
HIS/HER KNOWLEDGE THE STATEMENTS HEREIN ARE TRUE AND COMPLETE. THE INSURER IS
AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION. SIGNING THIS
APPLICATION DOES NOT BIND THE INSURER TO ISSUE, OR THE APPLICANT TO PURCHASE, ANY
INSURANCE POLICY.
THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE
INSURER. IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE
EFFECTIVE DATE OF THE POLICY, THE APPLICANT MUST NOTIFY THE INSURER, WHO MAY MODIFY
OR WITHDRAW THE QUOTATION.
(WORDS WITHIN QUOTATION MARKS ARE DEFINED IN THE INSURANCE POLICY.)
________
______________________________________ _______/_______/_______
Licensed Practitioner’s Signature Date
______________________________________________ _______/_______/_______
Signature of Applicant Date
______________________________________________
Name and Title
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