COMMUNITY HEALTH CENTER APPLICATION DEEMED UNDER THE FEDERAL TORT CLAIM ACT

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1 COMMUNITY HEALTH CENTER APPLICATION DEEMED UNDER THE FEDERAL TORT CLAIM ACT INSTRUCTIONS 1. Please read the instructions carefully. Complete and submit all requested information and/or required attachments. This application and all materials submitted shall be held in confidence. 2. All application questions must be fully answered. If a question does not apply, enter "N/A". 3. If additional space is required, continue on a separate sheet of your letterhead and indicate the question number. 4. Please provide copy of most recent FTCA Application for Medical/Dental Professional Liability Protection, Deeming Letter, and Uniform Data System (UDS) Report. GENERAL INFORMATION Name of Applicant Street Address City State Zip Code County Mailing Address (if different) Executive Director Address Telephone Number Fax Number Website URL 1. FTCA initial deeming start date: Deeming end date: a. Has there been any lapse in deemed status for the entity or individual providers? Yes No b. If yes, provide the dates and list services where lapse existed. 2. Named Insured: If more space is required, provide on the applicant s letterhead. a. Provide name, address and deemed status for all legal organizations applying for coverage. Name of Organization Address Deemed Entity (D) and/or Non-Deemed (ND) b. List and describe services out of scope/non-deemed services. Service Description CNA71176XX Community Health Center Page 1 of 6 Printed In U.S.A.

2 c. Are any sites at which services are provided operated by a sub-recipient or contractor? Yes No NA i) If yes, are all deemed services and deemed locations? Yes No NA ii) If not, explain. 3. Within the next 12 month period, does applicant plan to: a. Obtain another operation or entity? Yes No b. Add to the number of employees? Yes No c. Expand the number of locations? Yes No d. Eliminate/add current services? Yes No e. Operate in other states? Yes No If any of the above answers are yes, explain. f. Within the past five years has the applicant: Acquired any operations? Yes No Sold any operations? Yes No Discontinued any operations? Yes No If any of the above answers are yes, explain. 4. Annual Center Outpatient Visits Current Number Projected Number Deemed Non-deemed Deemed Non-deemed 5. Additional Deemed YES/NO Non-deemed YES/NO Pharmacy $ Laboratory $ Imaging $ Home Health Care/Home Care Visits Hospital/ED Coverage on-call arrangements NOT required as a condition of employment School Based Clinics Health Fair-Adult Immunizations Providers Teaching at non-approved sites Residential Treatment Food Bank/Meals Providers performing peer review not required as a condition of employment Other (describe) Revenue OR # as applicable (Non-deemed Only # Visits Provider FTEs # Visits # Immunizations # Immunizations Provider FTEs # Beds # Meals served Provider FTEs CNA71176XX Community Health Center Page 2 of 6 Printed In U.S.A.

3 6. Staffing Profile by Number of FTEs PERSONNEL BY CATEGORY Medical/Clinical Director Family Practice General Practitioners Internists OB/GYNs Pediatricians Other Specialty Physicians Employees/Contractors Working more than an avg. of 32.5 hours/week (Deemed) Specialty Providers Employees (defined by the FTCA) (Non-deemed) Working less than an avg. of 32.5 hours/week (Deemed) Contractors Volunteers (Non-deemed) Physician Assistants Nurse Practitioners Certified Nurse Midwives Pharmacists Dentists/Dental Surgeons Psychiatrists Psychologists Other Licensed Independent Professionals (Describe) 7. Does the applicant require individuals not covered by the FTCA to carry professional liability insurance? Yes No NA 8. If yes, indicate the minimum professional liability insurance limits required. $ each claim $ aggregate a. If yes, do you require proof of coverage? Yes No NA b. If you do not require these individuals to carry professional liability insurance, do you want coverage to include these individuals? Yes No NA If you are seeking coverage for these individuals with CNA, complete Roster. 9. Does the applicant require volunteers to carry professional liability insurance? Yes No NA a. If yes, indicate the minimum professional liability insurance limits required. $ each claim $ aggregate b. If yes, do you require proof of coverage? Yes No NA c. If you do not require volunteers to carry professional liability insurance, do you want overage to include volunteers? Yes No NA d. (If you are seeking coverage for these volunteers, complete Roster.) 9. Do interns/medical residents or others provide primary care rotations at the applicant s health center? Yes No a. If yes, is the training covered by the FTCA deeming letter? Yes No b. If the training is not covered by the FTCA deeming letter, what entity is responsible for providing insurance coverage? Applicant Health Center Medical School Other (if Other define) c. If training is provided by the Applicant Health Center, do you want coverage to include interns/medical residents? Yes No NA d. If yes, what is the average number of FTE s per week? CNA71176XX Community Health Center Page 3 of 6 Printed In U.S.A.

4 10. Does the community health center arrange with local community providers to provide afterhours coverage to community health center patients? Yes No a. If yes, is this arrangement approved within Scope? Yes No NA b. If the arrangement is not approved within Scope do you require the other entity and providers to maintain insurance? Yes No NA 11. Are newborn deliveries performed? Yes No OB/GYNS Specialty Annual # of Deliveries Deemed Annual # of Deliveries Non-deemed Family Practitioners Certified Nurse Midwives Other Provider (describe) 12. Does the applicant control, operate or manage (in whole or in part), any hospital, nursing home, ACO or other institution where medical care is provided? Yes No If yes, describe: 13. Does the organization participate in clinical trials or research programs? Yes No If yes, describe. 14. Contractual Agreements a. Does the applicant contract with any organization/entity to provide professional services? Yes No b. Does the applicant require the contracting party to carry professional liability insurance with limits equal to/or exceeding the applicant s? Yes No NA c. Does the applicant require the contracting party provide an in force copy of a certificate of insurance? Yes No NA d. List organizations/entities with whom you contract. Name of Organization/Entity Description of Deemed or Non-Deemed 15. GENERAL LIABILITY a. Does applicant sponsor any sporting or special events? Yes No If Yes, explain? b. Does the applicant provide alcoholic beverages at any of these events? Yes No NA If Yes, explain? c. Is all advertising/public relations media/website reviewed by legal counsel or risk management? Yes No 16. Litigation/Claims History/Sanction/Fines (Applicable to all Employees/Contractors) If the response is yes to any question below, additional information must be provided on the applicant s letterhead. Please submit actual loss runs from the previous carriers for the past five or more years. a. Has the applicant or Employees/Contractors had any Professional, General Liability, Employee Benefits, Umbrella claims, or suits brought against them in the past 5 years? Yes No b. Is the applicant aware of any incident (including requests for medical records), circumstance, or occurrence which may result in a claim and which has not been reported to another carrier? Yes No c. Has the applicant s or an employee s/contractor s professional/facility/operationallicense ever been suspended, revoked, or voluntary suspended? Yes No d. Has any Insurance Company or Lloyd s declined, canceled, or refused to renew or accept any of the applicant s or employee s/contractor s liability insurance? Yes No CNA71176XX Community Health Center Page 4 of 6 Printed In U.S.A.

5 e. Has any Company with whom the applicant been previously affiliated with become insolvent? Yes No f. Has any federal, state civil or criminal investigation or action been initiated or filed that directly, or indirectly involve the applicant s organization or an employee/contractor? Yes No g. Has the applicant ever been sanctioned or decertified by Medicare? Yes No h. Has any employee, contractor, or volunteer been convicted for an act committed in violation of any law or ordinance other than a traffic offense? Yes No i. Has the organization or any of its officers, administrators or staff, been sanctioned or had disciplinary actions brought against them by federal or state authorities, any professional medical society, accreditation agency or other governmental or non-governmental oversight entity? Yes No 17. Coverage Requested (check all that apply) a. Professional Liability Current Insurance Carrier: Premium: $ Retroactive Date: Limits of Liability: $ each claim/$ aggregate What is Deductible Amount $ Does the state the applicant is operating in have a Patient Compensation Fund? Yes No If yes, is the applicant currently enrolled in the Patient Compensation Fund? Yes No NA b. Commercial General Liability Current Insurance Carrier: Premium: $ Current Form of Insurance: Check one: Occurrence Claims Made Retroactive Date: Limit - Each Claim (cannot exceed PL limit) $ Limit - Fire Damage Limit of Liability (Any one Fire) $ Limit - Products-Completed Ops Aggregate Limit $ Limit - General Aggregate (Other than Products) $ What is Deductible Amount $ c. Umbrella Liability * Do not have an Umbrella policy Want an Umbrella policy Current Insurance Carrier Premium $ Limit $ Combined Single Limit *Submit Umbrella Accord Application for this coverage. Include Auto and EL information if you desire to have this coverage scheduled on your umbrella policy. d. Employee Benefit Liability: Do not desire this coverage Want coverage Limits of Liability: $ each claim / $ aggregate Total number of Employees e. Have the limits of liability changed since your original retroactive date? Yes No If yes, provide limits structure by policy year. CNA71176XX Community Health Center Page 5 of 6 Printed In U.S.A.

6 FRAUD NOTICE WHERE APPLICABLE UNDER THE LAW OF YOUR STATE 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 MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES (for New York residents only: 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.) (For Pennsylvania Residents only: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.) (For Tennessee Residents only: Penalties include imprisonment, fines and denial of insurance benefits.) AUTHORIZATION Signature Above in Full Date Name Above (Please Print) Agency Name and Address Person submitting application Telephone Number Address This product will be underwritten in one of the CNA property/casualty companies. CNA is a registered service mark and trade name of CNA Financial Corporation CNA71176XX Community Health Center Page 6 of 6 Printed In U.S.A.

7 Community Health Center Roster for Employees/Contractors/Volunteers Name of Applicant Date Name Specialty MD DO PhD DDS/DMD PharmD NP PA CNM Other FTE Hours per week for Deemed Hours per week for Non- Deemed Retroactive Date Description of Exact Locations are Provided Claims/ Lawsuits over past 5 years? (If yes, explain.) Has the individual operated in the past or currently under a restricted license? (If yes, explain.) Comments/Notes

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