MEDICAL GROUP PRACTICE PROFESSIONAL LIABILITY APPLICATION

Transcription

1 BY COMPLETING THIS, THE APPLICANT IS APPLYING FOR INSURANCE WITH EXECUTIVE RISK INDEMNITY INC. NOTICE: THE POLICY FOR WHICH THIS IS MADE CONTAINS CLAIMS MADE AND REPORTED COVERAGE FOR CERTAIN INSURING AGREEMENTS. SUCH INSURING AGREEMENTS ONLY APPLY TO "CLAIMS" FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD AND REPORTED TO THE UNDERWRITER DURING THE "POLICY PERIOD" OR WITHIN SIXTY (60) DAYS AFTER THE END OF THE POLICY PERIOD. IF AN EXTENDED REPORTING PERIOD IS APPLICABLE, SUCH COVERAGE WILL APPLY ONLY TO CLAIMS FIRST MADE AGAINST THE INSURED DURING THE EXTENDED REPORTING PERIOD AND REPORTED TO THE UNDERWRITER DURING THE EXTENDED REPORTING PERIOD. THE COVERAGE AFFORDED UNDER THIS POLICY DIFFERS IN SOME RESPECTS FROM THAT AFFORDED UNDER OTHER POLICIES. PLEASE READ THE ENTIRE CAREFULLY BEFORE SIGNING. A. APPLICANT 1. Group Practice Name ( Applicant ): 2. Primary Contact for Applicant: Position/Role: 3. Main Location Address: County: City: State: Zip Code: Telephone Number: 4. Length of time at main location: 5. Date Applicant was established: 6. Address: 7. Applicant s Website: 8. Tax Identification Number: 9. Additional Locations: If Yes, list all other locations on a separate sheet. 10. Does Applicant own its practice site? 11. Does Applicant own property that is leased to other entities? 12. Name and describe all legal entities affiliated with the Applicant (including but not limited to parent company, subsidiaries, joint ventures and partnerships) (*Note that coverage for such entities is not automatically provided; the terms and conditions of the Policy, if issued, will determine actual coverage.): a. Name and Address: Percent Owned: Operations Description: Relationship to Applicant: Coverage Requested? If Yes, retroactive date: b. Name and Address: Percent Owned: Operations Description: Relationship to Applicant: Coverage Requested? If Yes, retroactive date: C32111 (1/2003 ed.) 1 Form

2 c. Name and Address: Percent Owned: Operations Description: Relationship to Applicant: Coverage Requested? If Yes, retroactive date: (List any other entities on a separate sheet.) B. GENERAL INFORMATION 1. Has the Applicant, other associated entity or any member of the Applicant s organization ever lost a license or been placed on probation by any governmental licensing agency? If Yes, please explain: 2. Has the Applicant entered into any joint ventures or limited partnerships other than those previously described? If Yes, please explain: 3. Does the Applicant or any member(s) of the group, or members of Applicant s organization participate in any teaching programs? If Yes, please describe the type of programs and the name of the sponsoring institution: 4. Does the Applicant or members of Applicant s organization conduct any research activities or participate in any clinical trials? If Yes, please explain: 5. Within the next 12 months, does the Applicant plan to: a. Obtain another group practice or entity? b. Add to the number of locations? c. Expand the number of locations? d. Form any joint ventures, mergers, or acquisitions? e. Start any new services or activities? f. Add additional physicians? Explain any Yes answers: 6. In the last 12 months, has the Applicant: a. Discontinued any services or operations? b. Sold any locations? Explain any Yes answers: C32111 (1/2003 ed.) 2 Form

3 7. What are the types of services provided by the Applicant? (Check all that apply and indicate %.) Family or internal medicine % Pediatrics % Surgery % OB/GYN % Emergency Medicine % Cardiology % Orthopedics % ENT % Ophthalmology % Neurology % Radiology % Other (list): % 8. Physical Premises: (Applicant only needs to answer if requesting general liability coverage.) a. Describe Applicant s premises: Area (Sq. Ft.) Age Type of Construction # of Floors Type of Fire Protection b. Does the Applicant occupy the entire building? c. If Applicant s premises are co-tenanted, please provide a list of tenants on a separate sheet. 9. Does the Applicant reimburse its physicians for continuing education programs? 10. Is the Applicant or any of its facilities certified or accredited by any of the following? AAAHC ARC CAP JCAHO Other (list): 11. Is the Applicant a member of a national organization? MGMA AGPA Other (list): C. COVERAGE REQUESTED (*Note that requested coverage is not automatically provided; the terms and conditions of the Policy, if issued, will determine actual coverage.) 1. Medical Group Practice Professional Liability: a. Each claim Limit of Liability: $ Annual Aggregate Limit of Liability: $ b. Retention Amount: $ or SIR Amount: $ c. Is coverage for prior acts being requested? If Yes, to what date? d. Is coverage to apply separately for each physician or will it be shared with the corporate entity? Individual Limits Shared C32111 (1/2003 ed.) 3 Form

4 e. Will physicians carry same limits of liability as the corporate entity or will they maintain different limits? Same Different If the physicians maintain different limits of liability, what are the limits? $ D. PREVIOUS MEDICAL INSURANCE COVERAGE Please list five prior years (if different from current year). 1. Current Year: Insurance Company: Policy Number: Limits of Liability: $ Deductible / Retention / SIR amount: $ Coverage: Claims Made Occurrence Retroactive Date: Policy Period: Entities Covered: Premium: $ 2. First Year Prior: Insurance Company: Policy Number: Limits of Liability: $ Deductible / Retention / SIR amount: $ Coverage: Claims Made Occurrence Retroactive Date: Policy Period: Entities Covered: Premium: $ 3. Second Year Prior: Insurance Company: Policy Number: Limits of Liability: $ Deductible / Retention / SIR amount: $ Coverage: Claims Made Occurrence Retroactive Date: Policy Period: Entities Covered: Premium: $ C32111 (1/2003 ed.) 4 Form

5 4. Third Year Prior: Insurance Company: Policy Number: Limits of Liability: $ Deductible / Retention / SIR amount: $ Coverage: Claims Made Occurrence Retroactive Date: Policy Period: Entities Covered: Premium: $ 5. Fourth Year Prior: Insurance Company: Policy Number: Limits of Liability: $ Deductible / Retention / SIR amount: $ Coverage: Claims Made Occurrence Retroactive Date: Policy Period: Entities Covered: Premium: $ MISSOURI APPLICANTS/AGENTS: DO NOT ANSWER QUESTION Has any insurer ever cancelled, non-renewed or reduced coverage? If Yes, please provide details: 7. Does the Applicant currently purchase Directors and Officers liability insurance? If Yes, please provide the following: Insurance Company Name: Limits of Liability: Past Acts Exclusion Date: Policy Period: Retention or Deductible: Policy Premium: 8. Does the Applicant currently purchase Employment Practices liability insurance? If Yes, please provide the following: Insurance Company Name: Limits of Liability: Retroactive Date: Policy Period: Retention or Deductible: Policy Premium: C32111 (1/2003 ed.) 5 Form

6 E. PERSONNEL 1. Administration: a. Name of Chief Executive Officer: How long with the Applicant? b. Name of Medical Director: How long with the Applicant? c. Name of Administrator or Manager: How long with the Applicant? d. Name of Risk Manager: How long with the Applicant? 2. Physicians: (individual applications are required) Please indicate number of: Full-time Physicians Part-time Physicians Dentists Podiatrists Total Current Year First Prior Year Second Prior Year Please explain any year-to-year change that occurred in excess of 10% 3. Contractors: a. Has Applicant ever utilized independent contractors or locum tenens? If Yes, is Professional Liability coverage required of independent contractors or locum tenens? If Yes, what Limits of Liability are required? $ b. Are they currently covered on the current policy? Current number of contracted independent contractors or locum tenens: C32111 (1/2003 ed.) 6 Form

7 4. Support Staff: Employees and Contractors: In Section A below, please indicate the total number of full-time equivalent employees (FTEs) / contractors by classification. If any employees are to be provided separate individual limits for their own acts of a professional nature, indicate so by checking Yes. An additional charge will be applied. A supplemental application must be completed for each person listed in Section A of the classifications who requests, or is required to have, individual coverage. If No, Section A providers would share in the same limit of liability as the Applicant. a. Classifications: Section A: FTEs Individual Coverage Section B: FTEs Midwife Audiologist Nurse Anesthetist Laboratory Technician Nurse Practitioner Nurse (LPN and RN) Optometrist Operating Room Tech. (Nonsurgical) Paramedic Perfusionist Physical Therapist Pulmonary Therapist Physician Assistant X-ray Technician (without therapy) Psychologist X-ray Technician (with therapy) Surgeon Assistant Medical Assistants (CNAs) Other (list): Clerical Staff (please specify and attach list of other miscellaneous medical personnel) Scrub Nurse Other (list): (please specify and attach list of other miscellaneous medical personnel) Total Section A Personnel Total Section B Personnel This classification applies to physician assistants or surgeon assistants who have completed an approved course of study leading to national certification and appropriate licensure (if required by state) and who perform their duties under the direct supervision of a licensed physician or surgeon, assisting in the group practice and/or research endeavors of the physician or surgeon. C32111 (1/2003 ed.) 7 Form

8 b. What was the average turnover rate of Applicant s support staff for the last two (2) years? 5. Licensure: Are all physicians, surgeons, dentists and medical personnel utilized by the Applicant duly licensed / certified to practice medicine in your state? If No, please explain: 6. New Physicians: a. Are all perspective physicians required to be Board-certified? b. Are all perspective physicians required to be Board-eligible? If No, explain reasons: F. REVENUE INFORMATION 1. Revenue Mix Commercial / Fee for Service % Capitated % Other at risk revenue % Medicare / Medicaid % 2. If any portion of the revenue mix is derived from capitation, does the Applicant purchase capitation / provider stop loss insurance? If Yes, please provide the insurance company name, the policy period and the policy premium: 3. Please list all managed care organizations that the Applicant currently contracts with: 4. Does the Applicant have any exclusive agreement(s) with any of these managed care organization(s)? If Yes, which ones? 5. Does the Applicant currently have any hold harmless agreements in place? If Yes, please provide a copy. C32111 (1/2003 ed.) 8 Form

9 6. Does the Applicant or any employed physician of the group practice perform utilization review activities that are delegated by a managed care organization? If Yes, please explain: 7. Does the Applicant own, control, staff or receive revenue from one or more of the following: a. Facilities for overnight patient monitoring or care? b. Hospital? c. Surgicenter? d. Urgicenter or walk-in clinic e. Emergency Room? f. Birthing Center? g. Substance Abuse Program? h. Radiation and/or Shock Therapy? i. Laboratory? j. Emergency Vehicles? k. Radiology Center? l. Optical Goods Store? (Annual Gross Sales $ ) m. Hearing Aid Store? (Annual Gross Sales $ ) n. Weight Control Clinic? Name: 8. Pharmacy: a. Does the Applicant have a pharmacy? If Yes, is it owned and operated by the Applicant? If No, please complete the following questions: Please provide the name of the entity that owns/operates the pharmacy: Is this entity required to carry professional liability insurance? Is a certificate of insurance from this entity required? What are the minimum limits of liability that the pharmacy is required to carry? Is the Applicant named as an additional insured on the pharmacy s policy? C32111 (1/2003 ed.) 9 Form

10 b. Is the pharmacy licensed? Is the pharmacy supervisor a licensed pharmacist? c. Does the pharmacy repackage or re-label any products under its own name? d. Does the pharmacy require that all manufacturers provide liability information for the products that it sells? e. Is the pharmacy in compliance with all local, state and federal laws that govern the manufacture, control, dispensing and distribution of prescription drugs? G. HOSPITAL RELATIONSHIPS 1. Specify hospitals at which Applicant s physicians hold staff or courtesy privileges: Hospital Name: Number of Physicians with Staff Privileges Number of Physicians with Courtesy Privileges Is Hospital JCAHO Accredited? Yes Yes Yes Yes Yes No No No No No H. RISK MANAGEMENT 1. Does Applicant have a written loss control / risk management program? If Yes, please attach a copy. 2. Does the plan include the following risk management elements: Generic or critical indicator screening of medical charts? Incident Reporting? Patient Complaints? Claims Handling? Contract Review? 3. How often is the program reviewed and updated? 4. Does the Applicant have a Peer Review or Medical Review Committee? 5. Does the Applicant have patient arbitration agreements? If Yes, what do these agreements cover: C32111 (1/2003 ed.) 10 Form

11 6. Please describe how fee-related complaints are handled: 7. a. Does the Applicant have written policies and procedures in place for credentialing, recredentialing, and making decisions which adversely affect a physician s status or privileges? b. Who does the credentialing? c. How does the Applicant respond to adverse actions taken by any other entities (such as limitations placed on a physician s hospital privileges)? d. Do the Applicant s credentialing procedures follow JCAHO or NCQA standards and comply with all applicable laws? e. Does the Applicant query the National Practitioner Data Bank, the Federation of State Medical Boards, or the State Board as part of the credentialing process? f. How often does the Applicant recredential physicians? g. Does the Applicant restrict the practice of any physician who has a mental or physical disorder or substance abuse problem that may impair his/her ability to practice? h. Are terminated physicians offered a fair hearing process prior to termination? i. Are the credentialing decisions made by a peer review committee? j. Does the Applicant credential and recredential allied health professionals? 8. Does the Applicant utilize informed consent forms? If Yes, what procedures are the forms used for? I. HAZARDOUS MATERIALS 1. How does the Applicant dispose of contaminated materials, human tissue, nuclear waste or any other hazardous materials? 2. Does the Applicant have an EPA registration number? If Yes, attach the RCRA or Super Fund application forms. 3. Are oxygen and other gas cylinders used? If Yes, how and when are they stored? 4. Does the Applicant use radium or other isotopes? If Yes, describe safety precautions taken and type and frequency of tests for stray x-ray radiation, or attach a copy of the applicable policy and procedures: C32111 (1/2003 ed.) 11 Form

12 5. Do the floors and ceilings of any room in which radium and x-ray are used, have lead lining or equivalent protection? 6. Does all x-ray equipment comply with regulatory requirements? J. MEDICAL RECORDS PROCEDURES 1. Are Applicant s medical records: Centralized? Computerized? Locked and secured? 2. Are records reviewed periodically? If Yes, please explain who reviews records and how often: 3. How are record-keeping deficiencies handled? 4. Are all records kept at the Applicant s main location? 5. How long are medical records retained? 6. Has Applicant begun its HIPAA compliance requirements? 7. Is written authorization required to disclose medical information or records? K. CLAIMS HISTORY 1. Has any individual or entity proposed for coverage ever submitted to a liability insurer or risk transfer instrument any claim or given notice of any fact, situation, transaction, event, act, error or omission for a malpractice claim, suit or incident, either directly or indirectly? If Yes, please attach information about such losses for the last ten (10) years, including the current year and a breakdown of total incurred losses, paid losses, and outstanding losses, separated by year for professional liability and general liability. Please provide full details of any claim paid or outstanding during this period in excess of $100,000 (paid) or $50,000 (outstanding). 2. Other than claims or potential claims that have been reported to a previous liability insurer or risk transfer instrument, is any individual or entity proposed for coverage aware of any fact, circumstance, situation, transaction, event, act, error, or omission which they know or reasonably should know may result in a claim that may fall within the scope of the proposed insurance? For the purposes of this question, reasonably should know includes any act, error, omission or occurrence that alleged sexual, physical or emotional abuse or misconduct; or was the subject of any peer review; professional or specialty association investigation or review; FDA MedWatch report; internal review or investigation; inquiry by any accreditation or licensing entity; local, state or federal investigation; JCAHO near miss investigation; sentinel event report or root cause analysis; incident report investigation; written inquiry, notification or demand by legal counsel or matter submitted to legal counsel; mandatory report on professional conduct; or similar investigation or review. C32111 (1/2003 ed.) 12 Form

13 If Yes to either 1 or 2, please describe each claim, suit, or incident, regardless of its outcome, and attach a carrier claim report for the past ten (10) years. Include amounts paid and reserved. NOTE: WITHOUT PREJUDICE TO ANY OTHER RIGHTS AND REMEDIES OF THE UNDERWRITER, IT IS AGREED THAT ANY CLAIM, OR RELATED CLAIM, ARISING OUT OF ANY FACT, CIRCUMSTANCE, SITUATION, TRANSACTION, EVENT, ACT, ERROR, OR OMISSION THAT IS OR SHOULD HAVE BEEN DISCLOSED IN RESPONSE TO QUESTION K1 or K2 IS EXCLUDED FROM THE PROPOSED INSURANCE. PLEASE DISCLOSE ANY INFORMATION MATERIAL TO THE RISK THAT HAS NOT OTHERWISE BEEN ADDRESSED IN THIS. (PLEASE ATTACH ADDITIONAL SHEETS OF PAPER IF NECESSARY.) Please provide the following information along with other requested information. 1. The Applicant s last two audited financial statements and the last interim Financial Statement. If the Applicant is newly formed, pro forma financial statements and a business plan. 2. Specimen copy of the Applicant s contracts used when entering into agreements with physicians, health care organizations and managed care organizations. 3. Copy of Applicant s current professional liability policies. 4. Copy of the Applicant s latest accreditation report (AAAHC, JCAHO) if applicable. 5. Loss history as required in Section K., Claims History, above. 6. Copy of the Applicant s bylaws. 7. Copy of the Applicant s letterhead and any advertising or public relations brochures. 8. If Applicant has a Self-Insured Program: a. Copy of latest Trust financial agreement. b. Copy of Trust coverage wording. c. Latest financial statement of Trust fund. d. Latest actuarial review supporting the funding of the Self-Insured Retention. C32111 (1/2003 ed.) 13 Form

14 9. A listing of all physicians as well as their: a. Names b. Specialties c. Retroactive dates d. Start date with the Applicant Completion of this Application DOES NOT obligate the Underwriter to bind coverage. Notice to Applicant - Please read carefully. For the purposes of this Application, the undersigned authorized agent of the person(s) and the entity(ies) proposed for this insurance declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this Application and any attachments or information submitted with this Application (together referred to as the Application ) are true and complete. The Underwriter considers the Application, which is on file with the Underwriter, physically attached to any policy issued. The Underwriter will have relied upon this Application in issuing the policy. The Applicant authorizes the Underwriter to make any inquiry in connection with this Application. Accepting this Application does not bind the Underwriter to complete, or the Applicant to purchase, the insurance. If the information in this Application materially changes between the date of this Application and the policy effective date, the Applicant will notify the Underwriter which may modify or withdraw any quotation or agreement to bind insurance. The undersigned declares that the person(s) and entity(ies) applying for this insurance understand that: (i) such insurance applies only to Claims first made or deemed made during the Policy Period or any Extended Reporting Period; and (ii) the Underwriter will have no duty to defend any Covered Proceeding. Notice to Arkansas, Minnesota and 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, which is a crime. 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 policy holder 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 Agencies. Notice to District of Columbia, Maine, Tennessee and 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 may include imprisonment, fines, or a denial of insurance benefits. Notice to Florida Applicants: Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim or an application containing any false or misleading information is guilty of a felony of the third degree. 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 false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. C32111 (1/2003 ed.) 14 Form

15 Notice to Louisiana and 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 Maryland 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 may be guilty of insurance fraud. 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 Oklahoma Applicants: 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. Notice to Oregon and Texas Applicants: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law. 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. I hereby declare that the above statements and particulars are true and that I have not omitted or misstated any material facts and I agree that this Application shall be the basis for any insurance policy that is issued. APPLICANT BY (Chairman, CEO or President) TITLE DATE By Clinic Administrator DATE NOTE: This Application must be signed by the designated positions acting as the authorized agent(s) of all individuals and entities proposed for this insurance. C32111 (1/2003 ed.) 15 Form

16 REQUIRED INFORMATION PRODUCED BY (Insurance Agent) (Please print name) (Please sign name) INSURANCE AGENCY INSURANCE AGENCY TAXPAYER ID OR SOCIAL SECURITY NO. AGENT LICENSE NO. ADDRESS (No., Street, City, State, and Zipcode) ADDRESS SUBMITTED BY (Insurance Agency) INSURANCE AGENCY TAXPAYER ID OR SOCIAL SECURITY NO. AGENT LICENSE NO. ADDRESS (No., Street, City, State, and Zipcode) C32111 (1/2003 ed.) 16 Form