MPM Insurance Company of Kansas

Transcription

1 MPM Insurance Company of Kansas 287 N. Lindbergh Blvd. St. Louis, Missouri Toll Free: Fax: Send Completed Application To: Missouri Professional Management, LLC 287 N. Lindbergh, Blvd St. Louis, Missouri Toll Free: Fax: INITIAL APPLICATION FOR MEDICAL PROFESSIONAL LIABILITY INSURANCE CLAIMS MADE POLICY IMPORTANT: You are applying for CLAIMS MADE COVERAGE. For your own protection, report to your CURRENT insurer BEFORE YOUR CURRENT POLICY EXPIRES ANY: Incident which might lead to a claim; Request for medical records; Unfavorable result in treatment; Knowledge of a patient or family member who might consider bringing a claim against you. THIS APPLICATION WILL BE ATTACHED TO AND FORM A PART OF ANY POLICY THAT MAY BE ISSUED Applicant must personally complete this application. Please type or print legibly in black ink. You MUST attach a curriculum vitae (CV) to this Application. Your CV will be incorporated into this application and any policy that may be issued. You MUST attach the declarations page of your current policy. You MUST report all circumstances that might reasonably be expected to result in a claim or suit to the Company, even if you believe that the claim or suit would be without merit. If the applicant or claimant knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information for insurance, the applicant is guilty of a crime and may be subject to fines and confinement in prison. Every question must be answered. If a question does not apply to you, mark it N/A (not applicable). If space is insufficient for a complete reply, please attach a separate sheet. Incomplete answers and/or missing attachments may delay the processing of your application. This is an Application only. Completion of this Application or its receipt by MPM Insurance Company of Kansas (the Company ) or an agent or broker does not bind the Company to issue a policy to you. Before coverage can be bound or a policy issued, this Application must be approved by the Company s underwriting department and the initial payment must be received by the Company or its agent. MPM Insurance Company of Kansas Medical Professional Liability Policy Application 1

2 I. GENERAL INFORMATION 1. Name of Insured: (First) (Middle) (Last) (M.D./D.O./other) Primary Office Address: (Number) (Street) (City) (State) (Zip) (County) Mailing Address: (Number) (Street) (City) (State) (Zip) (County) Residential Address: (Number) (Street) (City) (State) (Zip) (County) Telephone/Fax Numbers: Office: ( ) - Office fax: ( ) - Cell: ( ) - Other fax: ( ) - Residence: ( ) - Direct Dial:( ) - Social Security # - - Date of Birth / / Please identify a person the Company may contact relating to the information contained in this application as well as future claims or incidents. Contact Name: Title: Direct dial telephone number: address: Please provide the name of all professional and/or medical societies of which you are a member. II. EDUCATIONAL BACKGROUND PLEASE ATTACH A COMPLETE COPY OF YOUR CURRENT C.V. (with all educational information including, but not limited to, medical school(s), internships, residency, type of residency, military training and experience). 2. State(s) where currently licensed: a. License # % of Practice b. License # % of Practice c. License # % of Practice 3. DEA License # MPM Insurance Company of Kansas Medical Professional Liability Policy Application 2

3 III. INFORMATION REGARDING YOUR PRACTICE A complete and accurate description of the nature of your practice is a condition precedent to coverage under any policy issued as a result of this application. Areas of your practice not fully and accurately described in this application will not be covered by any policy issued as a result of this application. 4. What is your current area of practice? Do you have a specialty? If YES, please describe Provide your practice history: Present (type of practice) Prior (type of practice) Prior (type of practice) (City and State) (City and State) (City and State) from / / to / / from / / to / / from / / to / / 5. Please explain any breaks of more than 3 months in your training or practice: 6. Changes in Practice: Have your practice procedures, specialty or location changed in the last ten years? If YES, please explain Changes in practice procedures, specialty or location during the period of any policy issued as a result of this application will not automatically be covered. You must notify the Company of any change in your practice within 30 days of any such change. Changes will not be covered unless endorsed onto the policy. 7. How many hours of continuing medical education do you attend annually: 8. Foreign medical school graduates: Are you certified by Education Commission for Foreign Med School Graduates (ECFMG)? Do you hold the foreign equivalent of board certificates? If YES, please explain 9. Are you Board Certified in a Specialty or Subspecialty (Must be recognized by the American Board of Medical Specialist or the American Osteopathic Association)? Specialty % of Practice Board certified? Subspecialty % of Practice Board certified? 10. If not board certified, are you board eligible? If YES, expected date you plan to become board certified / / If NO, please explain 11. Type of practice: Solo Partnership Employee Solo and Professional Assn. Professional Assn. Contractor Solo and Professional Corp Professional Corp Resident Correctional Institution Indicate if you: Share professional employees MPM Insurance Company of Kansas Medical Professional Liability Policy Application 3 Nursing Homes Share calls # of physicians, outside your group, with whom you share calls? Common billings Share profits Other (describe) Other (describe)

4 12a. Name of every Corporation, Association, Partnership or Employer you have been associated with or employed by after the date you have requested for your Retroactive Date: Is this a Missouri entity? Is this a Missouri entity? Is this a Missouri entity? Is this a Missouri entity? 12b. Which entity(ies) listed in Question 12a are you currently employed by or associated with? 13. For which of the entities described in Question 12a do you wish to obtain insurance coverage for your acts? 14. Please provide the information requested below for all medical doctors, doctors of osteopathy, physicians, surgeons, dentists, anesthetists, physicians assistants, optometrists, clinical psychologists, nurses, registered nurses, nurse practitioners, certified registered nurse anesthetists, emergency medical technicians, pharmacists, podiatrists, chiropractors, physical therapists, certified nurse midwives, midwives and advanced practice nurses employed by or associated with you or your group: Name Dates of Employment Present Insurer Policy Number Expires 15. How many of the following non-physician individuals are employed by or associated with you or your group? Acupuncture Technicians Clerks (non-medical) Medical Assistants Other (describe and provide number) 16. Total Number of employees/agents: 17. List below the name of each individual currently employed by or associated with you or your group (if not previously listed in questions #14-15): Name Title 18a. Are any of the individuals listed in questions #15 through #16 independent contractors? If YES, do the independent contractors have their own individual coverage? If YES, please provide a certificate of insurance. If NO, describe the coverage arrangements: MPM Insurance Company of Kansas Medical Professional Liability Policy Application 4

5 18b. Since the Retroactive Date requested, have you employed or provided supervision to, whether pursuant to a collaborative agreement or other arrangement, any other person (including advanced practice nurses and physicians assistants) licensed, certified or otherwise authorized to provide advanced health care services in the absence of direct supervision by a licensed physician? If YES, and you are seeking coverage for your liability arising out of that agreement or arrangement, please provide the following information for each such person, complete Form G, G and attach a copy of such agreement or arrangement: Name Specialty Employee Supervise Only Any policy issued as a result of this application will not provide coverage for collaborative practice agreements or arrangements unless such agreements or arrangements are disclosed to the Company and endorsed onto the policy. If you enter into any such agreement or arrangement after a policy is issued, and you desire coverage for such agreement or arrangement, you must contact your broker within 30 days of entering ering into such agreement or arrangement to seek an endorsement to the policy. 19. Since the Retroactive Date requested, have you engaged in any moonlighting activity? 20. Since the Retroactive Date requested, have you worked in an urgent care center, free-standing emergency center, or similar setting? 21. Since the Retroactive Date requested, have you worked in an industrial clinic? 22. Since the Retroactive Date requested, have you worked in a free-standing birthing clinic or similar facility? 23. Since the Retroactive Date requested, have you functioned as a hospitalist? If YES, provide the name of the hospital and describe the duties performed: If you answered YES to any of the above questions #19 through #23, please explain (include in explanation the name of entity, location, duties, number of hours worked and whether separate malpractice was provided for such activity): _ 24. Since the Retroactive Date requested, have you served on a trauma team? Please explain any YES answers: 25. Volume of practice (weekly average): Number of patients seen by you in office: Number of patients seen by you in hospital: Number of patients seen only by paramedical personnel employed by you: Average weekly total per week per week per week Please indicate average number of hours per week: MPM Insurance Company of Kansas Medical Professional Liability Policy Application 5

6 Office practice hours Emergency room hours Hospital practice hours On-Call hours If Part-Time (less than 21 hours per seven-day week and no more than 1, 000 hours per year): When did you start practicing part-time: / / Are you involved in another part-time practice for which you have coverage? If YES, please explain If you are applying for Part-Time Coverage, please complete Form H Request for Part-Time Coverage. 26. List additional practice locations including all offices, nursing homes, public health centers, urgent care clinics and other non-hospital locations. Type of Practice (i.e., additional private practice office, nursing home, clinic, etc.) Number Street City State Zip County % of Practice time at this location Telephone # Fax # Address 27. Since the Retroactive Date requested, describe any practice outside your office location, such as rounds at a hospital and/or practice in another state: 28. Since the Retroactive Date requested, have you treated patients that were admitted to nursing homes by other physicians? 29a. Since the Retroactive Date requested, have you utilized medical subcontractors or medical agents, on or off site, for purposes of providing professional medical services? If so, explain who and under what circumstances? 29b. Since the Retroactive Date requested, have you utilized remote off-site radiology services to read films on behalf of yourself, or your practice, including but not limited to teleradiology services? If so, explain who and under what circumstances? MPM Insurance Company of Kansas Medical Professional Liability Policy Application 6

7 IV. HOSPITAL AFFILIATIONS 30a. Hospitals granting you privileges Nature of privileges % work in each # of years b. If you do not have admitting privileges, please describe in detail your procedure for handling your patients who may require immediate in-patient care. 30c. Have any hospital staff or clinical privileges been revoked, restricted, suspended, limited, refused or subject to investigation? If so, explain 31. Since the Retroactive Date requested, have you provided emergency care? If YES, was the work for your own patients only? Was your work required for staff privileges? Was there a written contract or agreement? (If YES, attach copy) Was insurance coverage provided by the facility for your work? V. OTHER AFFILIATIONS 32. Do you have any affiliations where you practice medicine or have an ownership interest, affiliation, joint venture or other arrangement outside your private office practice listed in questions 12a and 12b (i.e., clinics, laboratories, etc.)? a. If YES, Name of facility Department Are you: Sole owner Executive officer Partial owner Medical director Administrator Physician with teaching responsibilities Department or ancillary service director b. Type of contractual agreement: Oral Written (submit copy) c. How many hours per week in the capacity(ies) above? hours per week d. What % of your gross billings in the capacity(ies) above? % of gross billings d. Is insurance coverage provided by the entity? If NO, is coverage being sought under this policy? If YES, give full details of practice. VI. PROCEDURES RES 33a. Since the Retroactive Date requested, have you performed any surgery in your office? If YES, please list types of procedures: 33b. Does your office have emergency resuscitation equipment? 34. Since the Retroactive Date requested, have you performed any surgery in other non-hospital MPM Insurance Company of Kansas Medical Professional Liability Policy Application 7

8 facilities? If YES, facilities: surgical procedures: 35. Since the Retroactive Date requested, in the course of any surgery described in questions #33a through #34, has any general anesthesia been administered: by you? by others? 36. Since the Retroactive Date requested, have you ever personally provided or do you currently provide pre-operative examination and post-operative care for all surgical patients? If NO, please explain: 37. Since the Retroactive Date requested, have you obtained written (please attach copy) or verbal informed surgical consent from your patients? 38. Since the Retroactive Date requested, please indicate by marking which procedures you have performed. Provide explanations in the tes Section where necessary. A complete and accurate description of the procedures you have performed is a condition precedent to coverage under any policy issued as a result of this application. Procedures not fully and accurately described in this application will not be covered by any policy issued as a result of this application. Complete the chart that follows on the next page. MPM Insurance Company of Kansas Medical Professional Liability Policy Application 8

9 Abortions Number of Therapeutic Abortions Over Last 12 months Acupuncture Therapeutic/ Local Anesthetic General Spinal/Caudal Anesthetic Amniocentesis Coronary Angiography Cerebral Angiography Angioplasty Arthroscopy Arteriography Hospital Surgery as Primary Surgeon Assisting in Surgery Own Patients Only Own & Other Than Own Patients Spinal Surgery If yes, list types and frequency: Blepharoplasty Brow Lifts Cosmetic Reconstruction Breast Implants Cosmetic Reconstruction Cosmetic Surgery* Major Minor Scar Revisions Sclerotherapy Suction Lipectomy* Bronchoscopy Blepharopigmentation Cardiac Catheterization Right Heart Left Heart Cataract Surgery Cryosurgery (other than external lesions) ERCP Electroconvulsive Therapy Endoscopy Laparoscopic Procedures Laser Surgery List types and procedures: Liposuction Major Gynecological Surgery Needle Biopsy Nerveblocks Lumbar Epidural Steroid Paraspinal Sciatic Facet Paravertebral Peripheral Occipital Triggerpoint Injection Paracentisis Phlebography Pnuemoencephalography Radial/Laser Keratomy Radiopaque Dye n-toxic Only Sigmoidoscopy Less than 60 cm Greater than60cm Colonoscopy Polypectomy Gastrointestinal Endoscopy Urological Implants Radiation Therapy Sex-Reassignment Surgery Silicone Injections Skin Flaps / Grafts Cosmetic Reconstruction Swan-Ganz Catheterization Weight Control Surgery/Therapy Drugs, list: % of practice Gastric Band Gastric Stapling Phenol / Chemical Facial Peel Diagnostic Embolization Fracture Reductions Open Close Tubal Ligations Eivasectomies Vasectomies Own Patients Only Own & Other Than Own Patients Prenatal Practice See Patients during First & Second Trimester See Patients but do t Perform Delivery See Patients to Term and Perform Delivery rmal Obstetrical Deliveries per year Cesarean Section per year Dental Related Fields (If yes, complete Form C) Other Procedures t Customary to Your Specialty. Please list: *If other than board certified or board Eligible Plastic Surgeon provide proof of training. Provide proof of training if received outside your residency MPM Insurance Company of Kansas Medical Professional Liability Policy Application 9

10 39. Are you seeking coverage during your Retroactive Period for any procedures and/or medical practice which you did not indicate in question #38? If YES, please list all procedures for which you seeking retroactive coverage that you did not indicate in question #38 in the tes Section. 40. ANESTHESIOLOGISTS Please complete Form F. F 41. DENTAL RELATED FIELDS Please complete Form C. C 42. PODIATRISTS Please complete Form I. I 43. FAMILY PRACTICE/GENERAL PRACTICE Provide a complete written description of your practice, including all procedures, and complete Form E. 44. GENERAL, THORACIC, VASCULAR and CARDIAC SURGERY Since the Retroactive Date requested, have you performed organ transplants? 45. OBSTETRICS AND GYNECOLOGY Please complete Form B. B 46. OPHTHALMOLOGY Provide a complete written description of your practice, including all procedures, and complete Form D. VII. CLAIM, INCIDENT AND INSURANCE HISTORY IMPORTANT: The Company will rely on the accuracy of all statements made in determining whether or not to issue a policy of insurance. Incomplete or incorrect information given by you, in the event of a claim, may lead to the denial of insurance coverage. In addition, any policy issued as a result of this Application will not cover any claims, conduct, circumstances, occurrences, accidents, or medical incidents likely to give rise to a claim which are known to you or which h should have been known to you on the date of this application, unless such is endorsed onto the policy. 47. List professional liability insurers for the past 10 years: Type of coverage form? Company Policy Number Limits From To Occurrence Claims Made / / / / / / / / / / / / 48. Whether you are applying for retroactive coverage or not, please provide a copy of your current policy including the declarations page and all endorsements, and state the annual premium amount. 49. Have you ever: a. been investigated, asked to resign or involved in official or nonofficial proceedings brought by a MPM Insurance Company of Kansas Medical Professional Liability Policy Application 10

11 hospital, managed care organization or other healthcare facility to deny, limit, suspend, nonrenew or revoke your privileges? b. had your membership in any professional society or association ever been suspended or revoked? c. had your license to practice medicine or your permit to dispense or prescribe drugs been limited, suspended, revoked, placed on probation or been voluntarily surrendered in any state? d. been notified to respond to, appear before or been investigated by any licensing or regulatory agency on a complaint of any nature, including, but not limited to, unprofessional or unethical conduct? e. been charged with or convicted of a felony or misdemeanor other than minor traffic violations? f. been evaluated, treated or hospitalized for any of the following (check if YES): alcoholism mental or emotional disorders central nervous system stimulants or depressants drug addiction g. had or become aware of having an illness or physical disability which impairs or could impair your ability to practice? If YES, please submit a letter from your treating physician addressing your state of health and whether any condition exists which could adversely affect your practice. h. had Medicare/Medicaid fraud charges filed against you? i. signed any contractual agreement in which you have agreed to indemnify (hold harmless) other persons or entities? (If so, please note the Company excludes indemnification or hold harmless agreements from coverage under its policies and, accordingly, will not be responsible for any liability incurred under such agreements.) j. been refused board certification? k. been under punitive or disciplinary observation, preceptorship or sponsorship in a hospital? l. been contacted by any hospital committee or group (other than an official peer review committee) that has reviewed (i) any issue regarding your delivery of medical services which you know or should have reason to know was of significant concern to a hospital where you have or had privileges, or (ii) any issue which arose out of any unexpected occurrence involving death or serious physical or psychological injury? m. had a grievance filed against you with any medical society, or have you been censured or received a private reprimand from any such organization? MPM Insurance Company of Kansas Medical Professional Liability Policy Application 11

12 If you answered YES to any a of the above questions #49a through 49m, please explain in the tes Section of this application. 50. Have you ever: a. been a party to a lawsuit alleging medical malpractice or negligence? b. had a claim for medical malpractice settled on your behalf with or without the filing of a lawsuit? c. received a letter from an attorney wherein the attorney states that you may have committed malpractice or acted negligently in the treatment of a patient? d. received a letter from a patient or relative of the patient wherein the patient or relative of the patient claims that you committed malpractice or acted negligently in the treatment of a patient? e. given a deposition in a lawsuit where you were not a party in the lawsuit but your employer was a party to the lawsuit and the lawsuit alleged medical malpractice? If you answered YES to any of the above questions #50a through 50e, please complete Form A Claim Report/A t/a-1 Incident Report for each affirmative answer. 51. Do you know of any facts or circumstances relating to or arising out of any patient care provided by you or others at your request or referral or direction which could possibly result in a claim being made against you, or your corporation, even if it is only a remote possibility in your mind and even if you believe the claim or suit would be without merit? If you answered YES to above question #51, please complete Form A-1 A Incident nt Report. 52. Since the Retroactive Date requested, are you aware of any of the following circumstances: a. A request for records from a patient and/or attorney related to an adverse outcome? b. A letter communication from a patient, patient s representative, friend, relative or attorney regarding your medical treatment of a patient? c. Intra-operative complications or other complications resulting in death, paralysis or other significant disabilities? d. Any unexpected or potentially problematic results or incidents occurred in the past five years in the following categories? i. Cardiac arrest ii. Postoperative coma iii. Postoperative neurological deficits iv. Unexpected death within 48 hrs. postoperatively v. All other post-operative complications MPM Insurance Company of Kansas Medical Professional Liability Policy Application 12

13 e. A request for the medical records of a patient who was deceased? f. A request for medical records of a patient who was admitted to a hospital as a result of an adverse reaction to medicine that you prescribed? If you answered YES to any of the above questions #52a through 52f please complete Forms A-Claim A Report/A-1 Incident Report for each affirmative answer. 53. Do you know of any facts or circumstances relating to or arising out of any patient care provided by you or others at your request or referral or direction which resulted in a patient, or a patient s representative, friend or relative becoming dissatisfied with the outcome of your procedure, treatment or diagnosis? If you answered YES to the above question #53, please explain in the tes Section. 54. Do you know, of any facts or circumstances relating to or arising out of any patient care provided by you or others at your request, referral or direction which have resulted in a claim or lawsuit that has not been reported to your current or prior professional liability carrier? If you answered YES to the above question #54, please complete Form A-Claim A Report. 55. Do you know, of any facts or circumstances relating to or arising out of any patient care provided by you or others at your request, referral or direction which have resulted in a claim or lawsuit that has been reported to your current or prior professional liability carrier? If you answered YES to the above question #55, please complete Form A-Claim A Report. MPM Insurance Company of Kansas Medical Professional Liability Policy Application 13

14 VIII. POLICY OPTIONS 56 Desired Effective Date / / 57. Limit of Liability Requested for individual applicant Each medical incident/annual aggregate (check one) $100,000/$300,000 $200,000/$600,000 $500,000/$1,000,000 $500,000/$1,500,000 $1,000,000/$1,000,000 $1,000,000/$3,000, Do you want prior acts coverage? If your current policy is, or any previous policies are, claims made, and you cancel the policy without purchasing an extended reporting endorsement (tail coverage), there will be no coverage for any claim from any act or omission that took place during that period of claims made coverage. However, you may apply for a policy with a Retroactive Date back to the first day of your previous claims made 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 tail coverage from your present carrier. Even if prior acts coverage c is written, it will not cover any claims, conduct, circumstances, occurrences, accidents, or medical incidents likely to give rise to a claim which are known to you or which should have been known to you on the date of this application, unless endorsed onto the policy. Retroactive Limit of Liability requested for individual applicant Each medical incident/annual aggregate (check one) $100,000/$300,000 $200,000/$600,000 $500,000/$1,000,000 $500,000/$1,500,000 $1,000,000/$1,000,000 $1,000,000/$3,000, Regarding entities you seek to insure, select one: Additional insured (no separate limit: no additional premium) Separate limit of coverage (additional premium required) Limit of Liability Requested for entities you seek to insure Each medical incident/annual aggregate (check one) $100,000/$300,000 $200,000/$600,000 $500,000/$1,000,000 $500,000/$1,500,000 $1,000,000/$1,000,000 $1,000,000/$3,000,000 Retroactive Limit of Liability requested for entities you seek to insure Each medical incident/annual aggregate (check one) $100,000/$300,000 $200,000/$600,000 $500,000/$1,000,000 $500,000/$1,500,000 $1,000,000/$1,000,000 $1,000,000/$3,000, Deductible requested (check one) ne $5,000 $10,000 $20,000 $30,000 $50,000 Other 61. Retroactive Date Requested for you: / / 62. Retroactive Date Requested for entity (see question 13): Name of Entity: Retroactive Date: / / Name of Entity: Retroactive Date: / / Name of Entity: Retroactive Date: / / MPM Insurance Company of Kansas Medical Professional Liability Policy Application 14

15 THIS APPLICATION WILL BE ATTACHED TO AND BECOME A PART OF ANY POLICY THAT MAY BE ISSUED. I hereby declare that my statements in this application and any attachments hereto are true and accurate and complete, and that I have not withheld any information that is reasonably likely to influence the judgment of the Company in considering this application for professional liability insurance. Up to the effective date of the policy for which I am applying, I agree to immediately notify the Company of any information, fact or circumstance that amends, modifies or changes any information contained in this application. I further agree to be bound by the Company s underwriting guidelines. I hereby state that I acknowledge and understand that the Company has published standard rates for coverage and that, due to underwriting, marketplace, type of practice, area of practice and past history reasons I may not be charged such rate by the Company for coverage and may be charged an increased rate. I hereby acknowledge and consent to such increased rate to be charged by the Company for medical malpractice coverage under the Company Policy. I hereby authorize the present and prior professional liability insurance carriers and any and all attorneys who have represented me in connection with any claim of professional liability to release to the Company upon its request for information regarding closed, pending, or anticipated claims and any underwriting or other information which in the judgment of any such carrier, attorney, or the Company may have a bearing upon my acceptability to the Company as a professional liability insurance risk. I also authorize all medical associations and medical societies in which I am or have been a member, all hospitals in which I now hold or have held staff privileges, the State Board of Medical Examiners for the State of Missouri and any other State in which I have practiced, or resided, and any and all entities and physicians having information regarding me, to release to the Company, upon its request, any information any such person or entity may have which in the judgment of any such person or entity or the Company may have a bearing upon my acceptability to the Company as a professional liability insurance risk. I hereby release and agree to hold harmless all persons or organizations releasing the information described above, their agents, servants, and employees, and the Company, its directors, officers, employees, agents, and members from any liability arising out of the release or use of any information released or furnished pursuant to this authorization, notwithstanding the fact that there may be errors, omissions, or mistakes contained in such released information. I hereby acknowledge that persons and organizations releasing information described above will be advised that their identity, and the information they provide, will be held in confidence and will not be disclosed to me. I agree that I shall not seek to discover or compel the disclosure, through judicial process, litigation or otherwise, of the identity of the persons or organizations releasing information described above or of the form or content of the information so provided, and I hereby expressly waive any right I may have to compel such disclosure. I further agree that the Company and all persons and organizations described above may rely upon a photostatic copy of the foregoing authorization, which shall be of equal validity with the signed original. I acknowledge that I am responsible for payment of all premiums regardless of whether anyone has agreed to pay premiums on my behalf. I understand and acknowledge upon acceptance of this application by the Company, this application shall become a part of the Policy and operate as a contract between me and the Company. With the submission of this application for insurance, I accept the following conditions during the processing and consideration of my application regardless of whether or not I am granted insurance and for the duration of the insurance which may be issued to me: To the fullest extend permitted by law, I extend absolute immunity to, and release from any and all liability, the Company, Missouri Professional Management, L.L.C., MPM Claims Management, L.L.C., MPM Client Services, L.L.C., and all of their respective directors, officers, agents, members, employees and other authorized representatives, for any acts pertaining to my application for insurance, including ultimate cancellations, rejection, or approval for insurance, and any communications, reports, records, statements, documents, disclosures, including otherwise privileged or confidential information, made or given in good faith with respect to such application. MPM Insurance Company of Kansas Medical Professional Liability Policy Application 15

16 I acknowledge that acceptance into the Company s insurance program is not a right of every applicant for insurance, and that my application will be evaluated by authorized management personnel and/or the Company s underwriting committee. Submission of a payment or deposit with this application and provisional receipt of such payment by the Company does not constitute acceptance for insurance nor the creation of an insurance contract. If an applicant is not accepted, any such payment shall be returned to the applicant. I further acknowledge that acceptance of advance payment does not bind the Company to provide insurance. I authorize the Company to release and discuss all information contained in this application and any information relating to any future claim or incident to the person I have designated as my contact in this application. Other than the incidents, events and claims disclosed on Forms A and/or A-1 attached hereto, since the Retroactive Date requested, there are no circumstances, acts, errors or omissions, known to me or of which I should reasonably be aware which could result in a professional liability claim against me or against any entity of which I am an employee, equity holder, officer or director. Additional signature is required on page 19 of this Application. Signature: Date: By my signature, I understand and agree that any policy issued to me will be issued in reliance upon the representations made herein which are warranted to be true and complete. I further understand and agree that failure to provide true and complete responses to the foregoing questions may, at the option of the Company, result in the voiding of insurance issued in reliance on this Application and/or denial of claims under any policy issued. Broker (Producer) Signature: Broker License : Date: An underwriter may contact you for further information or clarification. MPM Insurance Company of Kansas Medical Professional Liability Policy Application 16

17 BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT ( Agreement ) is executed in favor of the Company and shall be effective as of the effective date of any Policy issued by the Company as a result of this Application. Recitals The Company and the Insured have an insurer/insured relationship by virtue of a professional liability policy issued by the Company to the Insured (the Policy ). The Company and the named Insured(s) on the Policy are committed to complying with the Standards for Privacy of Individually Identifiable Health Information (the Privacy Regulations ) under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ). Under the Privacy Regulations, the Insured(s) is(are) a covered entity, and, as defined by 45 C.F.R (e) and 45 C.F.R (e), the Company is a Company of the Insured(s). The Company must use and/or disclose Protected Health Information in its performance of services under the Policy. The Company agrees to abide by the assurances, terms, and conditions contained herein in the performance of its obligations. This Agreement sets forth the manner in which Protected Health Information that is provided to, or received by, the Company, from or on behalf of the Insured(s) will be handled. The Company agrees as follows: Section 1 Definitions 1.1 Company: Company shall mean MPM Insurance Company of Kansas. 1.2 Covered Entity: "Covered Entity" shall mean the Insured(s) named in the Policy. 1.3 Designated Record Set: "Designated Record Set" means "Designated Record Set" as defined in 45 C.F.R Individual: "Individual" shall have the same meaning as the term "Individual" in 45 C.F.R and shall include a person who qualifies as a personal representative in accordance with 45 C.F.R (g). 1.5 Privacy Rule: "Privacy Rule" shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 C.F.R. parts 160 and 164, subparts A and E. 1.6 Protected Health Information (PHI): "Protected Health Information" (PHI) shall have the same meaning as the term "Protected Health Information" in 45 C.F.R , limited to the information received by the Company from, or on behalf of, Covered Entity. 1.7 Required by Law: Required by Law shall have the same meaning as the term required by law in 45 C.F.R Secretary: "Secretary" shall mean the Secretary of the Department of Health and Human Services or his/her designee. Section 2 Obligations and Activities of the Company The Company agrees to the following: 2.1 t to Use or Disclose PHI Unless Permitted. The Company agrees not to use, or further disclose, PHI other than as permitted or required by the Agreement or as Required by Law. 2.2 Use Safeguards. The Company agrees to use reasonable and appropriate safeguards to prevent use or disclosure of the PHI other than as provided for by this Agreement or as otherwise Required by Law. 2.3 Report Inappropriate Disclosures of PHI. The Company agrees to report to Covered Entity any use or disclosure of the PHI not permitted by this Agreement or Required by Law of which it becomes aware. 2.4 Compliance of Agents. The Company agrees to require and ensure that any agents, including subcontractors, to whom it provides PHI received from, or created or received by the Company on behalf of Covered Entity, agrees to the same restrictions and conditions that apply through this Agreement to the Company with respect to such information. 2.5 Access. To the extent the Company maintains the Designated Record Set, the Company agrees to provide access to PHI in the original Designated Record Set, during normal business hours, provided the Covered Entity delivers prior written notice to the Company, at least five business days in advance, requesting such access but only to the extent required by 45 C.F.R Amendments. To the extent the Company maintains the Designated Record Set, Company agrees to incorporate any amendment(s) to PHI in the original Designated Record Set that the Covered Entity directs, pursuant to 45 C.F.R Disclosure of Practices, Books, and Records. Unless otherwise prohibited by law, the Company agrees to make internal practices, books, and records which are directly related to the protection of PHI available to the Covered Entity or to the Secretary, during normal business hours, for purposes of the Secretary determining Covered Entity's compliance with the Privacy Rule. The Company shall have a reasonable time within which to comply with such requests and, in no case shall access be required in less than five business days after the Company's receipt of such request. 2.8 Accounting. The Company agrees to maintain sufficient documentation of any disclosures of PHI and information related to such disclosures as would be required for the Covered Entity to respond to a request by an Individual for an accounting of disclosures of PHI in accordance with 45 C.F.R MPM Insurance Company of Kansas Medical Professional Liability Policy Application 17

18 2.9 Release of Documentation of Disclosures. The Company agrees to provide to Covered Entity information collected in accordance with Section 2.8 of this Agreement, to permit Covered Entity to respond to a request by an Individual for an accounting of disclosures of PHI in accordance with 45 C.F.R The Company shall have a reasonable time within which to comply with such requests and, in no case shall access be required in less than five business days after the Company's receipt of such request Security of Electronic Protected Health Information (EPHI). The Company agrees to: (1) implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the EPHI that it creates, receives, maintains or transmits on behalf of Covered Entity; (2) ensure that any agent, including a subcontractor, to whom it provides such information agrees to implement reasonable and appropriate safeguards to protect it; and (3) report to the Covered Entity any security incident of which it becomes aware. Section 3 Permitted Uses and Disclosures by the Company 3.1 Use of PHI for Specified Purposes Under the Insurance Policy, the Company provides the Covered Entity with insurance products and services, hereinafter "Services that involve the use and disclosure of PHI as defined by the Privacy Regulations. These Services may include, among others, the provision of professional liability insurance; receiving and evaluating incidents, claims, and lawsuits; quality assessment; quality improvement; loss prevention tools; outcomes evaluation; protocol and clinical guidelines development; reviewing the competence or qualifications of health care professionals; evaluating practitioner and provider performance; conducting training programs to improve the skills of health care practitioners and providers; credentialing, conducting or arranging for medical review; arranging for legal services; conducting or arranging for audits to improve compliance and other functions necessary to perform these Services. Except as otherwise limited in this Agreement, the Company may use or disclose PHI on behalf of, or to provide services to, Covered Entity that are necessary for Company to perform its obligations under this Agreement, under law, and under the Insurance Policy. Moreover, the Company may disclose PHI for the purposes authorized by this Agreement: (i) to its employees, subcontractors, and agents, in accordance with paragraphs Section 3.2 through 3.4 of this Section below; or (ii) as otherwise permitted by the terms of this Agreement. All other uses not authorized by this Agreement are prohibited. 3.2 Use of PHI for Company Management and Administration. The Company may use PHI for the proper management and administration of the Company or to carry out the legal responsibilities of the Company. 3.3 Disclosure Required by Law or With Reasonable Assurances. The Company may disclose PHI for the proper management and administration of the Company and to carry out its legal responsibilities, provided that disclosures are Required by Law, or provided that the Company obtains the following reasonable assurances from the person or entity to whom the PHI is disclosed: 1) the PHI will remain confidential; 2) the PHI will be used or further disclosed only as required by law or for the purposes for which it was disclosed; and, 3) the person or entity will notify the Company of any instances of which the person or entity is aware in which the confidentiality of the information has been breached. 3.4 Data Aggregation Services. Company may use PHI to provide data aggregation services to the Covered Entity as permitted by 45 C.F.R (e)(2)(i)(B). Section 4 Impermissible Requests by Covered Entity The Company understands that the Covered Entity shall not request Company to use or disclose PHI in any manner that would not be permissible under the Privacy Rule if done by Covered Entity, except that, despite this Section 4, Company may use or disclose PHI for data aggregation or management and administrative activities of Company as is otherwise permitted by this Agreement. Section 5 Term and Termination 5.1 Term. The Term of this Agreement shall be effective during the term of the Insurance Policy between the Company and the Covered Entity, and shall terminate when all of the PHI provided by Covered Entity to Company, or created or received by Company on behalf of Covered Entity, is destroyed or returned to Covered Entity, or, if it is not feasible to return or destroy PHI, protections are extended to such information, in accordance with the termination provisions in this Section. 5.2 Termination for Cause. Upon Covered Entity's knowledge of a material breach by Company of this Agreement, Covered Entity shall provide an opportunity for Company to cure the breach. If Company fails or is unable to cure the breach after a reasonable period of time Covered Entity may terminate this Agreement. 5.3 Effect of Termination. Upon termination of this Agreement or the Insurance Policy, the protections of this Agreement will remain in force and Company shall make no further uses and disclosures of PHI except for the proper management and administration of its business or to carry out its legal responsibilities or as Required by Law. Section 6 Miscellaneous Provisions 6.1 Regulatory References. A reference in this Agreement to a section in the Privacy Rule means the Section in effect or as amended, and for which compliance is required. MPM Insurance Company of Kansas Medical Professional Liability Policy Application 18

19 6.2 Amendment. The Company agrees to take such action as is necessary to amend this Agreement from time to time as is necessary, as determined by the Company, for compliance with the requirements of the Privacy Rule and the Health Insurance Portability and Accountability Act, Public Law Survival. The rights and obligations of the Company under this Agreement shall survive the termination of this Agreement and the termination of the Policy. 6.4 Interpretation. Any ambiguity in this Agreement shall be resolved in favor of a meaning that permits Covered Entity to comply with the Privacy Rule. Signature: Date: MPM Insurance Company of Kansas Medical Professional Liability Policy Application 19

20 NOTES SECTION MPM Insurance Company of Kansas Medical Professional Liability Policy Application 20

21 Form A Supplement to Application Claim Report Please complete this form to report any claims or lawsuits relating to any patient care provided by you or others at your request or referral, even if you believe the claims or suits are without merit. Please otherwise utilize this form to respond to any questions on your application where you responded with a. [Attach copies of patients charts, operative notes or other documents as appropriate to explain the facts and circumstances.] If there has been more than one claim or lawsuit, please photocopy this form. Attach additional sheets if needed. All questions must be answered or marked t Applicable (N/A). 1. Name of Patient: Age: Sex: Address: City/State/Zip: 2. Date Reported to Insurance Company: 3. Name of Insurance Company: 4. Date of Claim: 5. Location of Claim: 6. Description, Extent, Nature and Type of Claim: 7. Extent and Nature of the Injury: 8. Present Condition of the Patient: 9. State how and when you became aware of this Claim: 10. Other physicians, insureds, professionals or entities involved: Name: Address: Telephone Number: Name: Address: Telephone Number: (Please attach a separate piece of paper if necessary.) MPM Insurance Company of Kansas Medical Professional Liability Policy Application Form A-1

22 11. Other Witnesses: Name: Address: Telephone Number: Name: Address: Telephone Number: (Please attach a separate piece of paper if necessary. ) 12. Did you in any way alter, embellish, delete, change, and/or destroy any records,, medical or otherwise, or were allegations made that you did so, pertaining to this Claim? 13. Status of Claim (check applicable answer): Suit threatened, no action taken Suit filed but dropped by claimant Suit Settled Out-of-Court a. Please provide the date the claim was paid and the amount paid / / $ b. Did you want to settle this claim? Awaiting mediation Awaiting court action - Reserve Amount: $ Summary Judgment in your Favor Court outcome in your favor Jury Verdict Directed Verdict Court outcome in favor of plaintiff Jury Verdict Directed Verdict Amount of Loss Payment: $ 14. Name and address of the attorney assigned to your case: 15. To your knowledge, was any settlement paid by another party involved (i.e., your P.A., P.C., partners, employees, etc.)? If yes, list settlement amount: $ MPM Insurance Company of Kansas Medical Professional Liability Policy Application Form A-2

23 16. Please provide any other relevant information: Signature: Print Name: Date: MPM Insurance Company of Kansas Medical Professional Liability Policy Application Form A-3

24 Form A-1 A Supplement to Application Incident Report Please complete this form to report any facts or circumstances relating to any patient care provided by you or others at your request or referral which could possibly result in a claim, even if it is only a remote possibility in your mind, and even if you believe the claim or suit would be without merit. Please otherwise utilize this form to respond to any questions on your application where you responded with a. [Attach copies of patients charts, operative notes or other documents as appropriate to explain the facts and circumstances.] If there has been more than one incident, please photocopy this form. Attach additional sheets if needed. All questions must be answered or marked t Applicable (N/A). 1. Name of Patient: Age: Address: City/State/Zip: Sex: 2. Date Reported to Insurance Company: 3. Name of Insurance Company: 4. Date of Incident: 5. Location of Incident: 6. Description of Incident: 7. Extent and Nature of the Injury: 8. Present Condition of the Patient: 9. Extent, Nature and Type of Claim Anticipated: 10. State how and when you became aware of this Incident: 11. Other physicians, insureds, professionals or entities involved: Name: Address: Telephone Number: MPM Insurance Company of Kansas Medical Professional Liability Policy Application Form A-1-1