Fillable Preferred Professional Insurance Company CORPORATION APPLICATION ADDENDUM (Risk Placement Services, Inc.)

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Preferred Professional Insurance Company CORPORATION APPLICATION ADDENDUM (Risk Placement Services, Inc.)

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Preferred Professional Insurance Company
®
CPP-100 Corp (08/15) Coverys Podiatry Preferred Page 1 of 4
CORPORATION APPLICATION ADDENDUM
If you own a corporation, partnership, LLC or other legal entity and you would like PPIC to provide the entity with a separate
limit of liability, please provide the following.
I. GENERAL INFORMATION
1. Name of Entity:
a) Other Name(s) under which the entity practices (e.g. DBAs):
b) Is the above a holding company: Yes No
If yes, are these subsidiaries such as (mark each type that is applicable):
Surgery Center Emergency Service Center
Urgent Care Center Any Type of Out-Patient Facility
MRI Facility Physical Therapy Facility
Lab Facility Other (please explain)
2. Legal Address:
Street
City
County
State
Zip
3. Billing Address:
(If different than above)
Street
City
County
State
Zip
4. Contact Person for Entity: Title:
5. Contact Email: 6. Contact Phone:
7. Website: 8. Fax #:
II. COVERAGE REQUESTED
9. 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 $
10. Prior Acts
a) If your expiring policy is on a Claims-made basis, are you exercising the option of purchasing extended reporting
period coverage?........................................................................................................................................................
Yes No
If no, do you want us to provide coverage for prior acts?........................................................................................... Yes No
Indicate the retroactive date you would like:
b) Please attach a copy of your most recent declarations page
c) Indicate reason for termination of latest policy:
Prior Acts Coverage is not granted automatically; therefore, it is important that you keep your present coverage current
and in force so that you do not forfeit your right to purchase extended reporting coverage from your present carrier.
CPP-100 Corp (08/15) Coverys Podiatry Preferred Page 2 of 4
III. PRACTICE INFORMATION
11. The entity is:
“Solo” Medical Corporation
Multi-Physician Shareholder Medical Corporation
Medical Partnership with Formal Written Agreement
Other
12. Contracts or Agreements
a) Does the entity have a written contract or agreement with a Medical Practice Foundation, Management Services
Organization or similar entity?
Yes No
If Yes, please attach a copy to this application
b) Does the entity render services under any other written contract or agreement? Yes No
If Yes, please attach a copy to this application
IV. PRIOR ACTS PERIOD
13. Practice History
Has the Corporation’s podiatrist roster changed, up or down, by more than 10% in the last five years?
Yes No
If Yes, please explain:
14. Professional Employees
Please list all professional employees that are CRNA’s, Physician Assistants, Surgical Assistants, Nurse Midwives, Chiropractors or
Dentists that have been employed by the entity in the last five years. Attach additional pages if necessary.
Name Job Title/Specialty
15. Insurance History
Complete the following chart to reflect the entity’s entire professional liability insurance history during the Prior Acts coverage period.
Begin with the entity’s current professional liability insurance carrier.
Note: To assist in answering this question, you may attach copies of all previous declaration pages and list all endorsements.
16. Insurance
Has any professional liability insurer canceled, declined, rescinded or modified coverage, or refused renewal,
excluding insurance company withdrawal?
(e.g. reduced limits, assigned a deductible, restricted coverage, surcharged rates)
Yes No
If Yes, please attach an additional page with full details.
17. Claims or Suits
a) Has the entity or any employee (other than a podiatrist) ever been notified of its involvement in a malpractice
claim, suit, or “incident” either directly or indirectly?
Yes No
b) As of this date, are you aware of any claims or suits made against the entity or of any conduct, circumstances,
incidents or accidents that are likely to give rise to a claim that have not been reported to the entity’s current
and/or prior insurer(s)?
Yes No
Please submit current claims history for all requested coverages for the past ten (10) years, if available. In the summary, include
the date of the event.
CPP-100 Corp (08/15) Coverys Podiatry Preferred Page 3 of 4
V. FRAUD STATEMENTS / WARNINGS
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, LOUISIANA, MARYLAND, RHODE ISLAND & WEST VIRGINIA APPLICANTS
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or 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.
*Applies in Maryland only
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 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.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS
WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other
person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially
related to a claim was provided by the applicant.
NOTICE TO FLORIDA and OKLAHOMA 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 (of the third degree)*. *Applies in Florida only
NOTICE TO KANSAS APPLICANTS
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, information concerning any fact
material thereto commits a fraudulent insurance act.
NOTICE TO KENTUCKY and 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)*. *Applies in New York only
NOTICE TO MAINE, TENNESSEE, VIRGINIA & 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 and denial of insurance benefits. *Applies in Maine only
NOTICE TO NEW MEXICO 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 civil fines and criminal penalties.
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 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 ALL OTHER 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 information 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.
CPP-100 Corp (08/15) Coverys Podiatry Preferred Page 4 of 4
DECLARATION AND CERTIFICATION:
THE UNDERSIGNED AUTHORIZED OFFICER OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE
TRUE, AND AFFIRMS THAT IF THE INFORMATION SUPPLIED IN THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS
APPLICATION AND THE EFFECTIVE DATE OF INSURANCE THE UNDERSIGNED WILL IMMEDIATELY NOTIFY THE INSURER OF
SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS
OR AGREEMENT TO BIND INSURANCE. FURTHERMORE, THE UNDERSIGNED DECLARES THAT THE SIGNING OF THIS FORM
DOES NOT BIND COVERAGE NOR COMMIT TO ORDERING COVERAGE.

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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Preferred Professional Insurance Company CORPORATION APPLICATION ADDENDUM (Risk Placement Services, Inc.)

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Completed 30 July 2020

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