Fillable MEDICAL MALPRACTICE PLAINTIFF SUPPLEMENT (Risk Placement Services, Inc.)

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MEDICAL MALPRACTICE PLAINTIFF SUPPLEMENT (Risk Placement Services, Inc.)

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MALP 0002 07 13 Page 1 of 2
MEDICAL MALPRACTICE – PLAINTIFF SUPPLEMENT
APPLICANT:
In respect of your “Medical Malpractice – Plaintiff Representation” area of practice only, answer the following:
1. List all attorneys involved in this area of practice.
Year
s experience # of cases handled
Name (in this area of practice) each year
2. How many years has the Applicant handled this area of practice?
3. Does the Applicant ever subcontract medical malpractice cases to any other law firm? Yes No
4. Does the Applicant ever undertake cases outside of your domiciled home state? Yes No
5. What percentage of your gross billings was derived from this area of practice?
Last 12 month %
Prior 12 months %
6. Total number of cases handled by the Applicant?
Last 12 month
Prior 12 months
7. Does the Applicant have a specialized department within your firm devoted to this area of practice?
Yes No
I understand the information submitted herein becomes a part of my Professional Liability Insurance Application and is
subject to the same representations and conditions.
Notice to Florida Applicants: 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 the
third degree.
Notice to New York Applicants: 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.
Signature of Owner, Officer or Partner Type Name and Title Date (month-day year)
Producers Must Complete:
Produced By (Insurance Agent or Broker):
Producer Name: Producer Signature:
Producer License No.: Date:
Broker Name
Broker Street
Broker City, State, Zip
Deerfield Insurance Company
Evanston Insurance Company
Essex Insurance Company
Markel American Insurance Company
Markel Insurance Company
Associated International Insurance Company
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MALP 0002 07 13 Page 2 of 2
Notice to Alabama Applicants; Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject
to restitution, fines, or confinement in prison, or any combination thereof.
Notice to Arkansas, District Of Columbia, New Mexico, Rhode Island And West Virginia 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 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 policyholder 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 Kansas Applicants: It is unlawful to commit a “fraudulent insurance act” which means 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 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, any information concerning any fact material thereto.
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 Maine, Tennessee, Virginia and Washington 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 Maryland Applicants: Any person who knowingly or willfully presents a false or fraudulent claim for payment of
a loss or benefit or who knowingly or willfully 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 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 Ohio Applicants: Any person who, with intent to defraud or knowing that he 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 any claim for the proceeds of an insurance policy containing any false, incomplete or misleading
information is guilty of a felony.
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 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 such person to criminal and civil penalties.
Notice to Vermont Applicants: Any person who knowingly presents a false statement in an application for insurance
may be guilty of a criminal offense and subject to penalties under state law.
Notice to Applicants of all other 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 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.
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MEDICAL MALPRACTICE PLAINTIFF SUPPLEMENT (Risk Placement Services, Inc.)

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Completed 23 November 2020

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