Malpractice Insurance For Allied Healthcare Students

Transcription

1 Malpractice Insurance For Allied Healthcare Students 1) Please print a copy of this application to your desktop printer. 2) Complete this hard copy by hand, answering all questions 3) Sign, date and either: a. Mail your completed application providing your credit card information OR with check payable to: CM&F Group, Inc., 99 Hudson Street, 12th Floor, New York, NY OR b. Fax your signed and completed application providing your credit card information (per the application) to CM&F Group, Inc. at (212) ) Once your application is processsed & approved, your policy will be mailed within 5-7 business days. Your payment --- whether by check or credit card -- will NOT be processed until your coverage has been approved.

2 Malpractice Insurance for Allied Healthcare Students Class Definitions Professional Class I Occupational Therapist Occupational Therapist Assistant Certified OT Assistant Respiratory Care Provider Respiratory Therapist Respiratory Therapist Technician/Technologist Professional Class II Art Therapist Dance Therapist Diagnostic Medical Sonographer Horticultural Therapist Music Therapist Recreation Therapist Professional Class III Audiologist Bio-Medical Technician/Technologist Blood Bank Technician/Technologist Cardiology Technician/Technologist Certified Laboratory Technician/Technologist Certified Medical Assistant Clinical Laboratory Technician/Technologist Community Health Assistant Community Health Technician/Technologist Dialysis Technician/Technologist Dietitian EEG Technician/Technologist Health Educator Histologic Technician/Technologist Laboratory Aide Medical Laboratory Technician/Technologist Medical Technician Medical Technician/Technologist Assistant Medical Technologist Medical Assistant Medical Records Administrator Medical Records Technician/Technologist Nuclear Medical Technician/Technologist Nutritionist Phlebotomist Radiation Therapist Radiologic Technician/Technologist Speech Hearing Therapist Speech Language Pathologist Surgeon Assistant Surgical Technician/Technologist X-Ray Machine Operator Professional Class IV Medical Dosimetrist Pharmacist Pharmacist (Consulting) Professional Class V-A Circulation Technician/Technologist Rehabilitation Assistant Rehabilitation Therapist Professional Class V-B Employed Physical Therapist Professional Class VI Corrective Therapist Enterostomal Therapist Exercise Physiologist Kinesiologist/Kinesiotherapist Massage Therapist Orthopedic Assistant Wellness Counselor Professional Class VII-A Athletic Trainer (Non-medical, Non-certified) Professional Class VII-B Athletic Trainer (Medical, LPT or RPT) Professional Class VII-C Electroneurodiagnostic Technician Professional Class VIII-A Volunteer EMT Professional Class VIII-B Basic/Intermediate EMT Professional Class VIII-C Paramedic Professional Class IX Physical Therapy Assistant Professional Class X-A Sports Medicine Instructor Sports Medicine Therapist Professional Class X-B Self Employed Physical Therapist

3 Malpractice Insurance for Allied Healthcare Students Rate Chart By Class Definitions Alabama, Alaska, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Hawaii, Idaho, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, Washington D.C., Wisconsin & Wyoming Class Student I II IV $26 V-A $35 V-B $35 - N/A in MA VI $40 VII-A $40 VII-B $81 VII-C $121 VIII-A N/A VIII-B N/A VIII-C N/A IX $26 - N/A in MA X-A $73 Kentucky residents only: Add $1.50 surcharge New Jersey residents only: Add.9% surcharge Arizona Class Student II $21 III $23 IV $28 V-A $38 V-B $38 VI $45 VIIA $45 VIIB $89 VIIC $134 IX $23 X-A $80 Georgia Class Student I II IV $25 V-A $34 V-B $34 VI $40 VIIA $40 VIIB $79 VIIC $119 IX $26 X-A $71 Maryland Class Student I II IV $22 V-A $30 V-B $30 VI $35 VIIA $35 VIIB $70 VIIC $105 IX $23 X-A $63

4 Malpractice Insurance for Allied Healthcare Students Rate Chart By Class Definitions Indiana Class Students I II IV $26 V-A $37 V-B $37 VI $40 VIIA $40 VIIB $81 VIIC $121 IX $26 X-A $73 West Virginia Class Students I III $21 IV $26 V-A $35 V-B $35 VI $41 VIIA $41 VIIB $81 VIIC $122 IX $26 X-A $73 New York Class Students I III $21 IV $26 V-A $35 V-B $35 VI $41 VIIA $41 VIIB $81 VIIC $122 IX $26 X-A $73 Texas Class Students I $22 II $24 III $26 IV $32 V-A $43 V-B $43 VI $51 VIIA $51 VIIB $101 VIIC $121 IX $33 X-A $91

5 Mail Completed Application To: CM&F Group, Inc. 99 Hudson Street, 12th Floor New York, New York (212) (800) Fax (212) GENERAL HEALTHCARE PROVIDER PROFESSIONAL LIABILITY Allied Health Application (1/00) Underwritten By: Granite State Insurance Company (A Capital Stock Company) 2704 Commerce Drive, Suite B Harrisburg, PA Producer Code 1. First Name Middle Initial Last Name Street Address Apartment No. City County State Zip Code Telephone # Fax # Address Professional License # 2. How did you hear about us? Convention Colleague Advertisement Mail CM&F Group Website Association (Please List) Other 3. I am: self-employed an employee 4. Please indicate your profession from the Class Definitions show below: CLASS DEFINITIONS Professional - Class I Occupational Therapist Occupational Therapist Assistant Certified OT Assistant Respiratory Care Provider Respiratory Therapist Respiratory Therapist Technician/Technologist Professional - Class III Audiologist Bio-Medical Technician/Technologist Blood Bank Technician/Technologist Cardiology Technician/Technologist Certified Laboratory Technician/Technologist Certified Medical Assistant Clinical Laboratory Technician/Technologist Community Health Assistant Community Health Technician/Technologist Dialysis Technician/Technologist Dietitian EEG Technician/Technologist EKG Technician Health Educator Histologic Technician/Technologist Laboratory Aide Medical Laboratory Technician/Technologist Professional - Class II Art Therapist Dance Therapist Diagnostic Medical Sonographer Horticultural Therapist Music Therapist Recreation Therapist Medical Technician Medical Technician/Technologist Assistant Medical Technologist Medical Assistant Medical Records Administrator Medical Records Technician/Technologist Nuclear Medical Technician/Technologist Nutritionist Pharmacy Assistant Pharmacy Technician/Technologist Phlebotomist Radiation Therapist Radiologic Technician/Technologist Speech Hearing Therapist Speech Language Pathologist Surgeon Assistant Surgical Technician/Technologist X-Ray Machine Operator Professional - Class IV Medical Dosimetrist Pharmacist Pharmacist (Consulting) Professional - Class V-B Employed Physical Therapist Professional - Class V-A Rehabilitation Assistant Rehabilitation Therapist Professional - Class VI Corrective Therapist Enterostomal Therapist Exercise Physiologist Kinesiologist/Kinesiotherapist Massage Therapist Orthopedic Assistant Wellness Counselor

6 Professional - Class VII-A Athletic Trainer (Non-medical, Non-certified) Professional - Class VIII-A Student/Volunteer EMT Professional - Class IX Physical Therapy Assistant Professional - Class VII-B Athletic Trainer (Medical, LPT or RPT) Professional - Class VIII-B Basic/Intermediate EMT Professional - Class X-A Sports Medicine Instructor Sports Medicine Therapist Professional - Class VII-C Electroneurodiagnostic Technician Professional - Class VIII-C Paramedic Professional - Class X-B Self Employed Physical Therapist *NOTE: This program does not cover psychologists, dental students, medical students or mental health counselors. 5. Please indicate desired (please check one): $500,000/$1,00,000 $1,000,000/$6,000,000 Are you an Indiana Resident electing to participate in the Indiana Patient s Compensation Fund? Yes No If yes, your Limit of Liability will be $250,000/$750, Have you ever been the subject of a reprimand or disciplinary action or refused employment or admission to a professional society or had your professional privileges suspended by any court or administrative agency or ever been the subject of any ethics investigation at a local, state or national level? Yes No If yes, please attach a separate sheet with full particulars. 7. Has any insurance ever been cancelled or non-renewed? *NOTE: Missouri Residents Do Not Respond. Yes No 8. Has any malpractice claim or suit ever been brought against you? Yes No If yes, please attach a separate sheet with full particulars. 9. Are you aware of any circumstances which may result in a malpractice claim or suit being made or brought against you? Yes No If yes, please attach a separate sheet with full particulars. 10. Please list your prior professional liability insurance, if any. INSURANCE POLICY LIMITS PREMIUM EFFECTIVE CARRIER NUMBER DATES The undersigned declares that the statements set forth herein are true. The undersigned agrees that if the information supplied on this application changes between the date of this application and the effective date of the insurance, he/she (undersigned) will immediately notify the company of such changes, and the company may withdraw or modify any outstanding quotations, authorization or agreement to bind the insurance. Signing of this application does not bind the applicant or the company to complete the insurance, but it is agreed that this application shall be the basis of the contract should a policy be issued, and it will be attached to and become a part of the policy. All written statements and materials furnished to the company in conjunction with the application are hereby incorporated by reference into the application and made a part hereof. The earliest effective date in which a policy can be issued is the date this application is received in our office. NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICA- TION 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 ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAY- MENT 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 INSUR- ANCE 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, INCOM- PLETE, 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 AUTHORITIES. 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.

7 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 ILLINOIS APPLICANTS: THE DISCOVERY OF ANY FRAUD, INTENTIONAL CONCEALMENT, OR MISREPRESENTATION OF MATERIAL FACT IN THE POLICY WILL RENDER THIS POLICY, IF ISSUED, VOID AT INCEPTION. THE DISCOVERY OF ANY FRAUD, INTENTIONAL CONCEALMENT, OR MISREPRESENTATION OF A MATERIAL FACT DURING A CLAIM WILL RENDER THIS POLICY, IF ISSUED, CANCELLED. 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 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 A DENIAL OF INSURANCE BENEFITS. NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND 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 MINNESOTA APPLICANTS: A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. 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 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. 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 (365: , ). NOTICE TO OREGON 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 ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. 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 TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFOR- MATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. NOTICE TO VERMONT 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 ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. Applicant s Signature: Title: Date: Name of Agent: Submitted by: Date: Address: Florida Agent License #: California Agent License #: (1/00)

8 PREPAYMENT REQUIRED Check or money order enclosed. I authorize CM&F Group, Inc. to charge the premium to my: VISA MASTERCARD Credit Card Account Number: Print name exactly as it appears on card: Charge premium to credit card. Expiration Month and Year: THIRD PARTY CREDIT CARD AUTHORIZATION CHARGE TO: VISA MASTERCARD Credit Card Account Number: Card Member Name (Print): Signature: Please complete the following (if payer other than applicant): Expiration Month and Year: Date Signed: MAIL TO: CM&F Group, Inc. 99 Hudson Street, 12th Floor, New York, NY FAX: info@cmfgroup.com Florida Applicants: Richard J.J. Sullivan, Jr. Non Resident License #A California Applicants: CMF Group, Inc. Non Resident CA License #OC