Fillable MALPRACTICE INSURANCE CHIROPRACTOR PROFESSIONAL LIABILITY APPLICATION - GEORGIA (Philadelphia Insurance Companies)

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MALPRACTICE INSURANCE CHIROPRACTOR PROFESSIONAL LIABILITY APPLICATION - GEORGIA (Philadelphia Insurance Companies)

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A. PERSONAL
1.
Full Name: Last: First: Middle:
2.
Date of Birth:
Age: Male: Female:
3.
Home Address:
City:
State:
Zip Code:
4.
Home Phone:
Website: www.
5.
Chiropractic License Number: State of Issuance:
6. As a Doctor of Chiropractic, you practice as a (SELECT ONLY ONE):
SOLE Practitioner CORPORATE Shareholder
PARTNERSHIP ASSOCIATE (Employed / Contracted)
B. PRACTICE
1.
Office Address:
City: County:
State: Zip Code:
2.
Office Phone: Fax:
Cell Phone: e-Mail:
3.
Years at Location:
FEIN
4.
Do you have a financial responsibility to any other practice location(s)? Yes No
(If Yes, address(es) and explanation on a separate sheet.)
5.
Are you incorporated? Yes No
Chiropractor Professional Liability
PI-CPHC-APP-DC GA 06/14
Page 1 of 9
© 2016 Philadelphia Consolidated Holding Corp.
05/2016
MALPRACTICE INSURANCE
CHIROPRACTOR PROFESSIONAL LIABILITY APPLICATION - GEORGIA
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C. STAFF / ASSOCIATES
1.
Clerks / Receptionists
Technicians
Other non-licensed professionals: (attach names and specialties)
2.
Approximately how many patient visits are treated by you and/or by the above staff during a typical
3.
Approximately how many hours of face time do you spend during a typical Practice week?
4.
Other than noted above, are there any other licensed medical professionals that are associated
with your practice?
(If Yes, give names, specialties, and extent of association on a separate sheet)
Yes
No
5.
Do you perform initial and interim examination of patients?
Yes
No
6.
Do you use progress notes that include subjective and objective findings in charting patient
visits?
D. NEW PATIENT PROTOCOL
1.
Obtain a medical history?
Yes
No
Formulate a differential diagnosis for treatment?
Yes
No
Obtain signed consent to treat?
Yes
No
Discuss the treatment planned?
Yes
No
Perform a physical exam?
Yes
No
Discuss the patient’s financial responsibility?
Yes
No
2.
With new patients, percent (approximately) that present to you with the following major complaint(s)
Cranial
Cervical
Lumbar
Extremity
Dorsal or Thoracic
Other:
3.
Approximately how many new patients are treated by you during a typical practice week?
Yes
No
Chiropractor Professional Liability
PI-CPHC-APP-DC GA 06/14
Page 2 of 9
© 2016 Philadelphia Consolidated Holding Corp.
05/2016
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E. MANIPULATION
1.
General Meric Adjusting:
Meric
Gonstead
Diversified
Motion Palpation
Pierce-Stillwagon
Thompson
Upper Cervical Specific:
Toggle
Hole In One
Grostic
Orthogonal
Instrumental Adjusting:
Life Cervical
Pettibon
Spinal Bio Physics
Activator
Equalizer
Kinesiology:
Bennett Reflexes
Reflexology
Applied Kinesiology
Direct Low-Forge:
Direct Non-Force Technique
Jenness
Freeman
Trigger Points
Receptor Tonus
Toftness
Sacro-Occipital:
Logan Basic:
Cox-Mc Manis:
F. THERAPIES
1.
Do you do Meridian therapy?
Yes
No
(If Yes, check all you do):
Acupressure
Electric Acupunture
Needle Acupuncture
Laser Acupuncture
2.
Check any / all physiotherapies used in patient care that are listed below:
Traction:
Mechanical
Motorized
Inversion
Intersegmental
Equipment:
Short-Wave Diathermy
Low / Hi Volt Galvanism
Tens Current
Inferential
Infra Red
Ultraviolet
Accuscope
Ultrasound
Whirlpool
Muscle Stimulating Current
G. X-RAYS
1.
Do you provide your own x-rays at your practice location?
Yes
No
(If Yes, answer below)
Does everyone who takes x-rays have proper and current certification / training?
Yes
No
Do you always use the 10-day rule for x-raying females of child-bearing age?
Yes
No
Chiropractor Professional Liability
PI-CPHC-APP-DC GA 06/14
Page 3 of 9
© 2016 Philadelphia Consolidated Holding Corp.
05/2016
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H. SPECIALTIES
1.
Venipuncture:
Yes
No
Obstetrics:
Yes
No
Reichian Therapy:
Yes
No
Invasive Surgery:
Yes
No
Sinus irrigation:
Yes
No
Chelation Therapy:
Yes
No
Gynecological Exams:
Yes
No
Colonic Irrigation:
Yes
No
Proctological Exams:
Yes
No
I. REFERRALS
1.
Do you have an established and working relationship with any of the medical specialists listed below?
Neuro Specialist
Orthopedist
Radiologist
Vascular Specialist
Internist
General Practitioner
2.
Do you have an established relationship to refer directly for diagnostic imaging?
Yes
No
J. MEDICAL POLICY
1.
Assess cerebral flow (i.e. palpate pulses, ausculate for bruits, Adson maneuver, etc.) prior to any cervical spine
Always
Usually
Occasionally
Never
2.
Always
Usually
Occasionally
Never
3.
Always
Usually
Occasionally
Never
K. BUSINESS POLICY
1.
Cash/Check
Charge Card
Barter
Statements
In Advance
On insurance assignment
(
With /
Without out of pocket)
On case contract
(
Installments
In advance)
2.
Indigent
Introductory
Referral
Community Service
Professional Courtesy
Educational
3.
Do you use a collection agency on past due accounts?
Yes
No
Chiropractor Professional Liability
PI-CPHC-APP-DC GA 06/14
Page 4 of 9
© 2016 Philadelphia Consolidated Holding Corp.
05/2016
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L. EDUCATION
1.
D.C. College:
Month / Year Graduated:
2.
Are you currently a member of and/or affiliated with any chiropractic Association and / or
Society?
Yes
No
(If Yes, identify)
3.
List any special chiropractic credentials and/or status that you have obtained:
M. CONFIDENTIAL INFORMATION
Answer the following questions and if your response is Yes, then describe on a separate sheet.
1.
Are you gainfully engaged / employed in any other profession and / or professional activity?
Yes
No
2.
Have you ever had professional liability insurance canceled or renewal refused?
Yes
No
3.
Have you ever used an intoxicant, narcotic, or other psychoactive or depressant drug to the
extent that it has interfered with your ability to perform professional duties?
Yes
No
4.
Have you ever been treated for alcoholism or drug addiction?
Yes
No
5.
Have you ever been involved in the loss or removal of a medical provider number?
Yes
No
6.
Have you ever had any state license to practice chiropractic revoked, suspended, or
involuntarily surrendered?
Yes
No
N. CLAIMS HISTORY
Provide patient names, dates, circumstances, details, status, etc. on a separate sheet for any “Yes”
answer below.
1.
Has the Applicant been involved in any malpractice claim(s) or suit(s)?
Yes
No
2.
Is the Applicant aware of any incidents which have occurred that might give rise to a claim
in the future?
Yes
No
3.
Is the Applicant aware of any other circumstances, injury, accident, error, omission, or offense
which may result in a claim being made against the Applicant or any of its predecessors in
practice or any of the past or present partners, owners, officers, or employees?
Yes
No
O. INSURANCE INFORMATION
1.
Do you currently have Malpractice Insurance?
Yes
No
If Yes, who is the carrier?
Is coverage Claims-Made or Occurrence?
2.
What is your current Retroactive Date, if any?
Retroactive Date:
3.
What limits of coverage are you applying for?
$100,00 / $300,000
$200,000 / $600,000
$500,000 / $1.5M
$1M/ $3M
Chiropractor Professional Liability
PI-CPHC-APP-DC GA 06/14
Page 5 of 9
© 2016 Philadelphia Consolidated Holding Corp.
05/2016
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4.
What is your proposed effective date of coverage?
5.
Do you currently have Premises Liability coverage? Yes No
If Yes, who is the carrier?
6.
Do you want coverage for your corporation, limited liability company or limited liability
partnership?
Yes
No
If Yes, what is the name of the entity?
Date
Q. MISCELLANEOUS ACKNOWLEDGEMENTS / AUTHORIZATION
1.
I hereby authorize release and exchange of information between my medical association or society and their
insurance consultants, an
y hospital I presently or previously held staff privileges with, and prior insurance carriers
involving past and future underwriting and claims matters. I further agree that the organization releasing the
information, its agents, servants and employees, shall not incur any liability as a result of any information released
or furnished pursuant to this authorization, including any errors, omissions, or mistakes contained in such released
information.
2.
I understand that the policy being applied for does not cover liability for others which I may have assumed under
any contract or agreement. I understand that the policy being applied for is limited to claims for professional
liability and that it does not provide coverage for property insurance, comprehensive general liability, owned or
non-owned automobiles, premises liability, or any other coverage.
3.
Submission of this application (signed or unsigned) to the company – with or without permission – does not bind
insurance coverage. Rather, insurance coverage will be put in force only when the insurance company issues a
wr
itten “Confirmation of Coverage’ or insurance policy. The insurance company will not issue a “Confirmation of
Coverage” until after it has:
a. Received and approved a completed application from you, and
b. Issued a written premium quotation to you based upon your application and certain other information, and
c. Received from you a written request to place coverage in effect, and
d.
Received from you either 100% of the correct premium, taxes, and fees which were quoted in the written
premium quotation discussed in “3b” above, or 25% of the correct premium and 100% of the taxes, and
100% of the fees which were quoted in the written quotation discussed in “3b”.
Date
Date
_______________________________________
Signature
________________________________________
Signature
________________________________________
Signature
Chiropractor Professional Liability
PI-CPHC-APP-DC GA 06/14
Page 6 of 9
© 2016 Philadelphia Consolidated Holding Corp.
05/2016
P.
PRACTICE REPRESENTATIONS
1
.
The undersigned Ap
plicant represents
, as a condition precedent to coverage, that he/she will not do any
of the following: practice obstetrics, perform procedures under 2 weeks of age, perform any invasive
s
urgical procedure, and/or do acupuncture with needles.
MISCELLANEOUS REPRESENTATIONS
1.
The undersigned Applicant represents that if the Applicant selects the insurance which is provided on a claims
made policy, then they are aware of the following: It only covers occurrences which take place during the policy
period and then only if the claim is first made to the company during the policy period or during a 60-day reporting
period commencing with the termination of the policy. The policy allows, for an additional premium, an extended
reporting period option. A sample policy is available on request.
________________________________________
Signature
Date
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Date
________________________________________
Signature
Chiropractor Professional Liability
PI-CPHC-APP-DC GA 06/14
Page 7 of 9
© 2016 Philadelphia Consolidated Holding Corp.
05/2016
2.
The undersigned Applicant represents, as a condition precedent to coverage, that he/she will provide immediate
written notice to the insurance company, prior to the inception of any coverage which may be offered by the
insurance company, of any occurrence, event, claim or suit of which the Applicant becomes aware, subsequent to
completion of this application, but prior to the inception of any coverage which may be offered by the insurance
company.
The Applicant further understands that failing to provide written notice to the insurance company, as provided in
Paragraph 1 above, will cause any coverage to be rescinded.
3.
The undersigned Applicant has read and understands this application and represents, as a condition precedent to
coverage, that all statements set forth herein are true, complete and accurate. The insured understands that this
application will be relied upon by the insurance company as it determines whether or not it will offer coverage (and,
if so, the price at which such coverage will be offered). As such, this application will become part of the insurance
contract (if such a contract is ultimately issued) and any false representation made on this application will cause
any coverage to be rescinded.
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge
and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this
Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information
in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the
Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
FRAUD NOTICE STATEMENTS
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 AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: 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 POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDLENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: 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 A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN NEW YORK: 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION TO BE COMPLETED BY THE
PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Chiropractor Professional Liability
PI-CPHC-APP-DC GA 06/14
Page 8 of 9
© 2016 Philadelphia Consolidated Holding Corp.
05/2016
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ADDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please identify the
question number to which you are referring.
_________________________________________________
Signature Date
Chiropractor Professional Liability
PI-CPHC-APP-DC GA 06/14
Page 9 of 9
© 2016 Philadelphia Consolidated Holding Corp.
05/2016
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