SERFF Tracking #: ZURC State Tracking #: Company Tracking #: CW OL 35534

Transcription

1 Product Name: Primary Health Care Liability Policy Endorsements Filing at a Glance Company: Product Name: State: TOI: Sub-TOI: Filing Type: Zurich American Insurance Company Primary Health Care Liability Policy Endorsements Wisconsin 17.0 Other Liability-Occ/Claims Made Professional Errors & Omissions Liability Form Date Submitted: 01/29/2013 SERFF Tr Num: SERFF Status: State Tr Num: State Status: ZURC Closed-Filed Co Tr Num: CW OL Effective Date Requested (New): Effective Date Requested (Renewal): Author(s): Reviewer(s): 03/01/ /01/2013 Jennifer Atilano Disposition Date: 02/04/2013 Disposition Status: Effective Date (New): Effective Date (Renewal): Shasta Hoffhein (primary) Filed

2 Product Name: Primary Health Care Liability Policy Endorsements General Information Project Name: Primary Health Care Liability Policy Endorsements Project Number: CW OL Reference Organization: Reference Title: Filing Status Changed: 02/04/2013 Status of Filing in Domicile: Not Filed Domicile Status Comments: Reference Number: Advisory Org. Circular: State Status Changed: Deemer Date: 02/27/2013 Created By: Jennifer Atilano Corresponding Filing Tracking Number: Filing Description: Submitted By: Jennifer Atilano We submit for review and approval, one new endorsement, U-HCU-908-A CW, Locum Tenens Health Care Providers. U- HCU-908-A CW is intended to be used with the Health Care Professional Liability Coverage Part previously approved under Serff Tracking Number ZURC Please see the Explanatory Memorandum for further details. Company and Contact Filing Contact Information Jennifer Atilano, Filing Analyst 1400 American Lane Schaumburg, IL Filing Company Information Zurich American Insurance Company 1400 American Lane Schaumburg, IL (847) ext. [Phone] [Phone] CoCode: Group Code: 212 Group Name: FEIN Number: State of Domicile: New York Company Type: State ID Number: Filing Fees Fee Required? Retaliatory? Fee Explanation: No No

3 Product Name: Primary Health Care Liability Policy Endorsements Correspondence Summary Dispositions Status Created By Created On Date Submitted Filed Shasta Hoffhein 02/04/ /04/2013

4 Product Name: Primary Health Care Liability Policy Endorsements Disposition Disposition Date: 02/04/2013 Effective Date (New): Effective Date (Renewal): Status: Filed Comment: Used with form filings that are subject to file & use under s (1)(c) and (1m) Wis. Stat. Effective July 1st, 2008, changes in insurance law exempted certain policy forms from receiving prior approval before use. This filing may be used 30 days after receipt by OCI. USE DATE:02/27/2013 Rate data does NOT apply to filing. Schedule Schedule Item Schedule Item Status Public Access Supporting Document Certification of Compliance and Readability Filed Yes Supporting Document Appraisal or Arbitration Provision Filed Yes Supporting Document Explanatory Memorandum Filed Yes Form Locum Tenens Health Care Providers Filed Yes

5 Product Name: Primary Health Care Liability Policy Endorsements Form Schedule Item Schedule Item Form Form Edition Form Form Action Specific Readability No. Status Name Number Date Type Action Data Score Attachments 1 Filed 02/04/2013 Locum Tenens Health Care Providers U-HCU- 908-A CW END New Form U-HCU- 908-A CW Locum Tenens - Health Care Providers.pdf Form Type Legend: ABE Application/Binder/Enrollment ADV Advertising BND Bond CER Certificate CNR Canc/NonRen Notice DEC Declarations/Schedule DSC Disclosure/Notice END Endorsement/Amendment/Conditions ERS Election/Rejection/Supplemental Applications OTH Other

6 Endorsement # Locum Tenens Health Care Providers Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff. Date of End. Producer Add l Prem. Return Prem. Named Insured and Mailing Address: Producer: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: Health Care Professional Liability - Claims Made Coverage Part Section II WHO IS AN INSURED, Paragraph B. is amended to include the following: Any temporary health care provider (locum tenens): Substituted for a physician, podiatrist, dentist, nurse midwife or certified registered nurse anesthetist who is: a. Employed by the Named Insured; and b. Included as an Additonal Insured under this Coverage Part, but only for their duties in such physician's podiatrist's, dentist's, nurse midwife's or certified registered nurse anesthetist's absence and on behalf of the Named Insured. Such substitution shall not exceed thirty (30) consecutive days. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. Includes copyrighted material of Insurance Services Office, Inc., with its permission. U-HCU-908-A CW (12/12) Page 1 of 1

7 Product Name: Primary Health Care Liability Policy Endorsements Supporting Document Schedules Item Status: Status Date: Satisfied - Item: Certification of Compliance and Readability Filed 02/04/2013 Comments: Attachment(s): Wisconsin Cert Signed.pdf Item Status: Status Date: Bypassed - Item: Appraisal or Arbitration Provision Filed 02/04/2013 Bypass Reason: n/a Item Status: Status Date: Satisfied - Item: Explanatory Memorandum Filed 02/04/2013 Comments: Attachment(s): Explanatory Memorandum U-HCU-908-A CW Locum Tenans - Health Care Providers.pdf

8 CERTIFICATE OF COMPLIANCE AND READABILITY I, Peter J. Eckardt (name), an officer of Zurich American Insurance Company (company name), hereby certify that I have authority to bind and obligate the company by filing this (these) form(s). I further certify that, to the best of my information, knowledge and belief: 1. The accompanying form(s) as identified by the attached listing comply(ies) with all applicable provisions of the Wisconsin Statutes and with all applicable administrative rules of the Commissioner of Insurance. 2. The form(s) does (do) not contain any inconsistent, ambiguous, or misleading clauses. 3. The form(s) does (do) not contain specification or conditions that unreasonably or deceptively limit the risk purported to be assumed in the general coverage of the policy form(s). 4. The only variations from a form currently on file with the commissioner of insurance and the only unconventional policy provisions are clearly marked or otherwise indicated pages n/a of the attached form(s) or in an attachment. 5. The attached form(s) is(are) in final format exactly as will be offered for issuance or delivery in Wisconsin, except for hypothetical data and other appropriate variable material. 6. If this form is a consumer insurance policy, the text of the form(s) meet(s) the minimum reading ease score or, if authorized by the commissioner, the score is lower than the minimum required by s. Ins 6.07(4)(a)1., Wis. Adm. Code. Product used to determine the Flesch score: n/a. LH 631 (Ed. 1/12) Wolters Kluwer Financial Services Uniform Forms TM

9 I understand that the commissioner of insurance will rely on this certification regarding the forms filed, and should it be determined that the policy form(s) does(do) not comply with the applicable laws, regulations, filing requirements and product standards or that this certification is materially false or incorrect, appropriate corrective and disciplinary action, including retroactive disapproval, as authorized by law, may be taken by the commissioner against the company and the officer completing this certification. (Signature) Vice President (Title) 1/28/2013 (Date) Individual responsible for this filing: Name: Jennifer Atilano Title: Regulatory Services Analyst Address: 1400 American Lane, Schaumburg, IL Phone Number: 847/ Date: 01/28/13 LH 631 (Ed. 1/12) Wolters Kluwer Financial Services Uniform Forms TM

10 Locum Tenens Health Care Providers U-HCU-908-A CW Explanatory Memorandum This filing is to submit one new endorsement, U-HCU-908-A CW, Locum Tenens Health Care Providers. U-HCU-908-A CW provides coverage for locum tenens health care providers as detailed in the endorsement replacing physicians employed and covered under the policy. U- HCU-908-A-CW is an optional endorsement at the request of the insured. The insured learns about the endorsement at the request of the insured's agent or broker. There is no rate impact associated with this endorsement. U-HCU-908-A CW is intended to be used with the Health Care Professional Liability Coverage Part.