1. Legal Name of the Primary Applicant: 3. Corporate Contact Name: 4. Corporate Contact Phone:

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1 PSIC RPG Association Large Group Dental Application A. APPLICANT Information 1. Legal Name of the Primary Applicant: 2. of Incorporation or Formation: MO/DAY/YR 3. Corporate Contact Name: 4. Corporate Contact Phone: 5. Corporate Contact Address: Your address will never be sold. It will be used to send you important messages. 6. Primary Office Address: Street City State Zip County 7. Mailing & Billing Address: q Primary Office Address q Other: Street City State Zip 8. Corporation Roster: CORPORATION ROSTER AND PRACTICE LOCATIONS Legal Name of Corporation % of Ownership Acquired FEIN Description/Purpose of Corporation 1 of 6

2 A. APPLICANT Information (continued) 9. Practice Locations: Street City State Zip County Please complete the Insured Dentist Supplement for all dentists to be covered. If additional space is needed, please include the information on a separate piece of paper. B. COVERAGE Information 1. q Claims-made coverage: Desired Retroactive : MO/DAY/YR 2. Please indicate the limits of liability requested for coverage or a quote (Not all limits may be available in all states): Limits of Liability: $ /per claim $ /per aggregate C. PRACTICE Organization INFORMATION 1. List all states in which the applicant has dental offices: 2. If applicant provides management services, describe management services performed: 3. In the next 12 months, does the applicant plan to do any of the following (please check all that apply): q Obtain another operation or entity q Eliminate or add services q Expand its number of locations q Operate in other states If yes to any of the above questions, please provide detailed explanation: 4. Please indicate by percentage where services are provided (Must total 100%): Applicant s office(s): % hospital: % Schools: % Patient s home: % mobile facility: % Jail/prison: % Long-term care facility: % Other, please describe: 2 of 6

3 D. PREVIOUS COVERAGE INFORMATION 1. Please provide a history of professional liability coverage for the last 10 years, including your current coverage and include the following: Insurance Company Name Policy Number Limits of Liability Range Premium Coverage Type Tail Coverage Purchased Retroactive E. ORGANIZATION INFORMATION If tail-coverage was purchased, please provide details. PLEASE PROVIDE WRITTEN EXPLANATION FOR ANY GAPS IN COVERaGe. if more room is needed, please use a separate piece of paper. 1. Does the applicant have a Dental Director?... If yes, please provide the following: Dental Director s name: Current insurance carrier, policy number, coverage type and limits: State of licensure, license number and date issued for each license held: Number of hours worked per week as Dental Director: 2. Does the applicant require all dentists and oral surgeons to carry professional liability insurance?... If yes, is this required by the employment agreement?... If not required by the employment agreement, please explain how compliance is enforced: 3. What is the minimum professional liability limit required? 3 of 6

4 E. ORGANIZATION INFORMATION (continued) 4. If claims-made coverage, is tail coverage for departed dentists purchased... If yes, who purchases?: 5. If purchased by the departed dentist, how is the purchase of tail coverage verified? 6. Please provide an explanation as to how either potential new dentists to be hired, or practices under consideration to be purchased by the group, are evaluated from a QA and risk management perspective: 7. In the last 10 years, has there been any review by any state dental board or other oversight entity of any dentist in the organization?... If yes, please provide an explanation of the circumstances and resolution: 8. In the last 10 years has any dentist, oral surgeon or allied healthcare professional had their dental license and/or DEA license suspended, revoked or voluntarily surrendered?... If yes, please provide an explanation of the circumstances and resolution: 9. Does any current dentist, oral surgeon or allied healthcare professional have any limitations or conditions on their license to practice?... If yes, please provide a list of practitioners and the details around their limitations and/or conditions: 10. Does the applicant use criminal background checks for all employees and/or independent contractors?... F. RISK MANAGEMENT 1. Does the applicant require a HIPAA compliant business associate agreement with all vendors, service providers and insurance company payers? Does the applicant require dentists who are independent contractors to carry liability insurance equal to or exceeding the applicant s coverage?... If yes does the applicant require proof of coverage via a current Certificate of Insurance? Does the applicant use a formal written Quality Improvement program? Is there a formal written peer review process in place? Does the applicant use a formal written Risk Management program? Please identify the individual(s) with overall responsibility for the Quality Improvement and Risk Management programs: 7. Please provide a copy of the Quality Improvement and Risk Management Protocols. 4 of 6

5 G. CLAIMS HISTORY Please provide applicant s current loss runs from previous carriers for the last ten (10) years. 1. Is the applicant aware of any incident (including requests for dental records or letters from attorneys or patients), circumstance or occurrence which may result in a claim and which has not been reported to another carrier? have any of the applicant s facilities operational licenses ever been investigated, suspended, revoked or voluntarily suspended? has the applicant ever been declined, canceled or refused to renew or accept professional liability coverage by an insurance company or Lloyd s of London insurance facility? has the applicant or any company the applicant has been affiliated with ever become or declared bankruptcy or insolvency? has any federal, state, civil or criminal investigation or action been initiated or filed directly or indirectly against the applicant or any owner of the applicant? Has the applicant ever been sanctioned or decertified by Medicaid or other insurance payor? has the applicant or any of its officers, directors or administrative staff been sanctioned or had disciplinary actions brought against them by federal or state authorities, professional dental societies, accreditation agencies or other governmental or non-governmental oversight agencies?... H. APPLICATION CHECKLIST Please remember to attach a copy of the following with the application: Your most recent declarations page. If claims are noted on the application, include a minimum of 10-years loss run from your current and prior insurance companies, and complete the Claim Information Form. Copy of dental licenses. Copy of the PSIC Insured Dentist Supplement. 5 of 6

6 I. Signature Required DO NOT CANCEL YOUR CURRENT INSURANCE POLICY UNTIL A BINDER OR POLICY HAS BEEN RECEIVED AND IS IN EFFECT FROM NCMIC INSURANCE COMPANY (NCMIC). THE ABOVE STATEMENTS ARE, TO THE BEST OF MY KNOWLEDGE, THE TRUTH, AND I HAVE NOT KNOWINGLY SUPPRESSED, WITHHELD OR MISSTATED ANY MATERIAL FACT IN COMPLETING THIS APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE. The undersigned represents and acknowledges that all information provided including the application, its supplements, attachments and answers to any questions our underwriter asks will be relied upon by NCMIC in determining whether to insure and at what rate to insure. I understand that the insurance for which I have applied is not in effect unless and until this application is accepted by NCMIC and I am notified by the company of said acceptance. I further acknowledge that, as a condition precedent to my acceptance, a detailed inquiry and investigation of my professional background, competence and qualifications may be conducted by NCMIC. In consideration of the foregoing, I hereby expressly consent to any such inquiry and investigation through the use of any means legally available to NCMIC, and I expressly release and discharge the company from any and all liability that might otherwise be incurred as a result of acts performed in connection with any inquiry or investigation as well as in the evaluation of information so received from whatever source. I further expressly authorize all individuals and entities to whom legal inquiry is made by NCMIC to provide the company with all information and/or documentation within their possession or under their control that pertains to my professional background, competence and qualifications, and I hereby release the providers of such information or documentation from all legal liabilities that might otherwise be incurred in connection herewith. I agree to notify NCMIC of any changes in my practice of dentistry within thirty (30) days of its occurrence, including but not limited to: Any changes in the professional services provided by me or someone for whom I am legally responsible; Any changes in my profession as described in any declarations issued as a result of this application; Any change in the location of my practice; Any investigation, restriction, suspension or surrender of a state dental license, DEA license or any hospital privileges; Any mental or physical condition that materially impairs my ability to practice dentistry, including treatment for alcohol or substance abuse; Any conviction, plea or agreement related to charges of a misdemeanor or a felony (other than a minor traffic offense). Important Reminder: If the coverage for which you are applying is written on a CLAIMS MADE basis, only claims first made against you and reported to NCMIC during the policy period are covered, subject to policy provisions. If you have any questions, please discuss them with your agent. Connecticut and Nevada Residents: 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 or knowingly helps with intent to defraud, commits a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. Florida Residents: 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. Dental malpractice insurance is offered through PSIC RPG Association. Coverage is underwritten by NCMIC Insurance Company. Signature of Applicant Signature of Soliciting Agent (Please Print Full Name) Agency Name 6 of 6

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