Fillable RENEWAL AH OUTPATIENT CLINIC Final (Kinsale Insurance)

Fill Online, Printable, Fillable, Blank RENEWAL AH OUTPATIENT CLINIC Final (Kinsale Insurance) Form

Use Fill to complete blank online KINSALE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

RENEWAL AH OUTPATIENT CLINIC Final (Kinsale Insurance)

On average this form takes 69 minutes to complete

The RENEWAL AH OUTPATIENT CLINIC Final (Kinsale Insurance) form is 6 pages long and contains:

  • 2 signatures
  • 160 check-boxes
  • 194 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kinsale Insurance forms online.

BROWSE KINSALE INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 6
RENEWAL APPLICATION FOR OUTPATIENT CLINICS
Instructions to the Applicant – please complete this application in ink and answer all questions completely. Attach extra sheets as
necessary should you run out of space provided. An incomplete or illegible application cannot be processed. Completion of this
application neither binds coverage nor guarantees that a policy will be issued.
• Provide a fully completed application, signed and dated by the owner, partner, or officer not earlier than 45 days before the
proposed effective date of coverage.
• If a question is not applicable, then state “N/A”.
GENERAL INFORMATION
1. Full name of Applicant (Including DBA’s) ___________________________________________________________________
2. Current Kinsale Policy Number: ________________________________________
OPERATIONS
7. Please check the category which best describes your organization
Health and Wellness Center
Primary Care Clinic
Urgent Care Center
Emergi-Center
Dental Clinic
Not for Profit Clinic
Other (please describe): ___________________________________________________________________
3. MAILING ADDRESS: __________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
4. LOCATION ADDRESSES: - Check here if no changes OR indicate all current locations below (use additional pages as needed)
(1) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(2) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
(3) ________________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
5. Inspection/Risk Management Contact Name:
6. Inspection/Risk Management Contact E-mail:
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
8. Please state sources and amounts of total revenue and patient contacts:
PATIENT VISITS / CLIENT CONTACTS
Source:
Charitable contributions
Government Funding
Fee for services
Other
– specify _________________
TOTAL GROSS REVENUES
LAST 12 months
$________________
$________________
$________________
$________________
$________________
NEXT 12 months
$________________
$________________
$________________
$________________
$________________
Emergency Visits
Urgent Care Visits
Health/ Wellness Visits
Other
– specify
___________________________
LAST 12 months
_______________
_______________
_______________
_______________
NEXT 12 months
_______________
_______________
_______________
_______________
10. Do you offer any of the procedures noted below? Additional information may be required.
If “Yes”:
Cosmetic / Aesthetic Procedures?
YES NO
Please Complete Medical Spa Supplement
Hormone Replacement Therapy?
YES NO
Please Complete Medical Spa Supplement
Erectile Dysfunction Therapy?
YES NO
Please Complete Medical Spa Supplement
Prenatal Care?
YES NO
Check all that apply:
1
st
Trimester 2
nd
Trimester 3
rd
Trimester
Abortions?
YES NO
*Coverage not currently available with Kinsale
Any surgical procedures?
YES NO
Please indicate surgical procedures below
Methadone or Suboxone Therapy
YES NO
Do you allow takeaways? YES NO
Total number of Slots*: ____________
Slots, defined as the maximum number of active patients
who could be enrolled / licensed client capacity.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
STAFF
11. Please indicate the current number of employed and contracted staff:
Number Employed?
Number Contracted
Insured
Elsewhere?
Coverage
Desired?
Full Time
Part Time
Full Time
Part Time
Acupuncturists
YES NO
YES NO
Chiropractors*
YES NO
YES NO
Dentists*
YES NO
YES NO
Inhalation/ Respiratory Therapists
YES NO
YES NO
Laboratory Technicians
YES NO
YES NO
Licensed Practical Nurses
YES NO
YES NO
Nurse Anesthetists
YES NO
YES NO
9. Since your last application to Kinsale have there been any major changes in exposures (acquisitions,
new or discontinued procedures / service offerings? If yes, please provide details below.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
YES NO
Page 3 of 6
Nurse Midwives*
YES NO
YES NO
Nurse Practitioner
YES NO
YES NO
Opticians
YES NO
YES NO
Optometrists
YES NO
YES NO
Paramedics/ EMT’s
YES NO
YES NO
Perfusionists
YES NO
YES NO
Pharmacists
YES NO
YES NO
Physician Assistant
YES NO
YES NO
Physicians – Major Surgery*
YES NO
YES NO
Physicians – Minor surgery*
YES NO
YES NO
Number Employed?
Number Contracted
Insured
Elsewhere?
Coverage
Desired?
Full Time
Part Time
Full Time
Part Time
Physicians – No surgery*
YES NO
YES NO
Physicians – OBGYN*
YES NO
YES NO
Physiotherapists
YES NO
YES NO
Registered Nurses
YES NO
YES NO
Social Workers
YES NO
YES NO
Speech Therapists
YES NO
YES NO
X-ray Technicians
YES NO
YES NO
Other: Specify
YES NO
YES NO
* Additional applications required if coverage is desired
CLAIMS HISTORY - Provide details for all “yes” answers to questions 12-17
12. Please provide the name and specialty of the applicant’s Medical Director:
________________________________________
Does the applicant’s Medical Director have direct patient care? YES NO
Full Time or Part Time
13. In the last 12 months, has the applicant or any of its employees ever had any professional license or
license to prescribe and or dispense narcotics ever been limited, suspended, revoked, denied, or
investigated by any licensing board or regulatory agency? Explain below or attach additional pages
as needed.
YES NO
14. In the last 12 months, has the applicant or any of its employees ever been charged with, or convicted
of a crime other than minor traffic violations? Explain on below or attach additional pages as
needed.
YES NO
15. In the last 12 months, has the applicant or any of its employees ever been diagnosed or treated for
alcoholism, drug addiction, any chemical dependency, or mental or chronic physical illness? Explain
on below or attach additional pages as needed.
YES NO
16. In the last 12 months, has any claim or suit for malpractice or professional liability ever been made
against the applicant OR any other person proposed for this insurance (to include any reports to
previous carriers)?
How Many? ______ (Complete Supplemental Claims form for Each.)
YES NO
17. Is the Applicant or any person proposed for this insurance aware of any act, error, omission, fact,
circumstance, or records request from any attorney which may result in a malpractice claim or suit?
If yes, please explain in detail, completing a supplemental claim form for each.
YES NO
18. Has any claim or suit for malpractice ever been made against the Applicant or any person proposed for
this insurance that has not been reported to the Applicant’s current or prior insurer? If yes, please
explain in detail, completing a supplemental claim form for each.
YES NO
Page 4 of 6
SUPPLEMENTAL INFORMATION Use the remainder of this page as needed or to address questions referenced within the application
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MARYLAND,
MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA,
OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING
APPLICANTS: In some 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, for the purpose of misleading, conceals information concerning any fact material thereto, may
commit a fraudulent insurance act which is a crime in many states.
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 policy holder 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 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 APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a
crime punishable by fines or imprisonment, or both.
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.
Page 5 of 6
NOTICE TO LOUISIANA 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 MAINE 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 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 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 YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value of the claim for each such
violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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 a 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 a 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.
NOTICE TO TENNESSEE 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 include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA 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 include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above
statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material
facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of any
policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon such
changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application and
made a part of this application.
Applicant:
_____________________________________
Title:
________________________________
FEIN #:
_____________________________________
Applicant’s Signature:
___________________________
Date:
________________________________
Agent / Broker Name:
_____________________________________________________________________
click to sign
signature
click to edit
Page 6 of 6
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.
Name of Patient:____________________________________________ Age:______ Sex:_______
Incident Claim
Date reported to insurance company: ______________
Name of insurance company: _______________________________________________
Date of incident and your treatment: __________________________________________________________
Allegations / Circumstances: ___________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Additional Defendants: _______________________________________________________________________
What is the present condition of the patient?______________________________________________________
___________________________________________________________________________________________
STATUS OF CLAIM
Suit threatened, no action taken Court outcome in YOUR favor: Unresolved/Open
Suit filed but dropped by claimant Jury verdict Awaiting mediation
Summary judgment in your favor Directed verdict Awaiting court action
Reserve amount:
$__________________
Suit settled out of court Court outcome in favor of plaintiff:
a. Date claim paid: _____________ Jury verdict
b. Amount paid: $_____________ Directed verdict
c. Did you want to settle? Amount of loss payment:
Yes No $_____________________
Name and address of the attorney assigned to your case: ____________________________________________
___________________________________________________________________________________________
To your knowledge, was any settlement paid by another party involved (i.e., your P.A., P.C., partners, employees, etc.)?
Yes: No:
Explain in detail what action(s) you have taken to prevent recurrence of this type of claim:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Signature: __________________________________ Date:_____________________
Printed Name: __________________________________
SUPPLEMENTAL CLAIM / INCIDENT INFORMATION
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

RENEWAL AH OUTPATIENT CLINIC Final (Kinsale Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document