HEALTH CARE FACILITY PROFESSIONAL/GENERAL LIABILITY INSURANCE APPLICATION (NON-GAP)

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1 HEALTH CARE FACILITY PROFESSIONAL/GENERAL LIABILITY INSURANCE APPLICATION (NON-GAP) I. GENERAL INFORMATION A. Name and Address of Applicant: Phone Number: ( ) Federal Tax ID Number: Fax Number: ( ) B. Ownership and Organization Type: Corporation For Profit Non Profit Governmental Partnership Individual C. Indicate percentage of physician and surgeon ownership (0-100%): % D. Please list all affiliates and subsidiaries, including their relationship to the applicant and their primary purpose. Indicate which affiliates or subsidiaries for which coverage is desired. E. 1. Is the facility licensed by the state: Yes No If yes, indicate type of license(s) held and license number: 2. Are any licenses restricted or conditional? Yes No If yes, please attach an explanation: F. Has any regulatory action ever been taken against the applicant or its management by any regulatory authority? Yes No If yes, please attach a description of the circumstances, penalties, and corrective actions taken. 09/07/01 1

Please list all affiliates and subsidiaries, including their relationship to the applicant and their primary purpose. Indicate which affiliates or subsidiaries for which coverage is desired. E. 1.

2 G. 1. Indicate the number of years the facility has been in operation: 2. Indicate the number of years under present management: H. Indicate professional association memberships: I. The facility operates as: Ambulance ( ground air) Drug/Alcohol Rehabilitation Center MRI Center Birthing Center Home Health Care Physical Rehabilitation Ctr Blood/Organ Bank Hospice Pregnancy Termination Ctr Community Health Center Laboratory, Clinical Pathology Surgical Center Dental Care Center Laboratory, Medical Urgent Care Center Dialysis Center Mental Health Facility Other, please describe: II. POLICY OPTIONS Requested Effective Date: Limits of Liability requested: Professional Liability / Each Person/Total General Liability / Each Occurrence/Aggregate Deductible amount requested: Coverage form requested: Occurrence Claims Made III. INSURANCE HISTORY Please indicate name, limits, expiration date of your current and previous professional liability insurer(s) Name of Insurer Policy Number Policy Period Limits of Liability Current coverage form: Occurrence Claims Made If currently claims made, indicate retroactive date: Was an extended reporting endorsement ( tail coverage) purchased? Yes No If yes, please attach a copy of the extended reporting endorsement. 09/07/01 2

Termination Ctr Community Health Center Laboratory, Clinical Pathology Surgical Center Dental Care Center Laboratory, Medical Urgent Care Center Dialysis Center Mental Health Facility Other, please

3 IV. PROFESSIONAL LIABIITY EXPOSURE A. Indicate the requested exposure for all medical services provided: Inpatient Services Number of Certified Beds Percent Occupancy Birthing Center % Substance Abuse-Rehabilitation % Hospice % Community Health Center % Crisis Stabilization % Mental Health Counseling % Urgent Care % Other (please describe): % Rehabilitation Services Developmental Disability % Physical Rehabilitation (Low Level) % Physical Rehabilitation (High Level) % Trauma (Low Level) % Trauma (High Level) % All Other Rehabilitation % Diagnostic and/or Treatment Visits Visits Surgical Visits Community Health Center Birthing Center all Crisis Stabilization Emergency Care Center Dialysis Surgi-Center Mental Health Counseling Pregnancy Termination Urgent Care All Other-Diag. &/or Treatment Ctr.* Rehabilitation Visits Visits Long Term/Home Care Visits Visits Cardiac Rehabilitation Home Care/Skilled Nursing Developmental Disability Home Care/Respiratory Physical Rehabilitation Home Care/Personal Substance Abuse Counseling Home Care/IV Therapy Trauma Rehabilitation Home Care/Durable Equip. All Other-Rehabilitation * Home Care/Hospice All Other Long Term/Home Care * 09/07/01 3

Health Center % Crisis Stabilization % Mental Health Counseling % Urgent Care % Other (please describe): % Rehabilitation Services Developmental Disability % Physical Rehabilitation (Low Level) %

4 Donor Banks Receipts Laboratory/X-Ray Visits/Receipts Blood Bank/Receipts Imaging-X-ray-MRI (Visits) Organ Bank/Receipts Medical Laboratory (Visits) Clinical Pathology Lab (Receipts) *If the nature of the services provided is not described above, please provide a description and the appropriate annual exposure unit amount expected. B. Does the applicant have a formalized Risk Management Program? Yes No C. Specify the policies and procedures in place for the management of patient emergencies: D. How are drugs and medications stored? E. Describe preventive maintenance of medical equipment? V. PROFESSIONAL EMPLOYEES A. Are all employed and contracted primary health care providers (including physicians and surgeons) required to carry their own medical professional liability coverage? Yes No If yes, what is the minimum limit of liability required? B. Please list below all employed primary health care providers (Physicians, Surgeons, Dentists, Podiatrists, CNMs, CRNAs, PAs, NPs, Chiropractors) Name Specialty Insurance Carrier Policy Number Limits of Liability Coverage requested? (Yes/No) If yes, a physician s application will be required for each employed physician for which coverage is requested. 09/07/01 4

Yes No C. Specify the policies and procedures in place for the management of patient emergencies: D. How are drugs and medications stored? E. Describe preventive maintenance of medical equipment? V.

5 VI. GENERAL LIABILITY EXPOSURE A. List all properties owned, controlled or occupied by the applicant: Address Description of Operations/Occupancy Area (Square Feet) Number of Floors Year Constructed B. Indicate any additional coverage needs, special remarks, or rating data not disclosed above (i.e. prescription drugs sold) C. Does the facility manufacture, sell, lease, or load any medical equipment or supplies? Yes No If yes, please describe and provide amount of annual receipts. VII. LOSS HISTORY A. Have any professional general liability claims or suits been brought against the applicant in the last five years? Yes No B. Do you have knowledge of any incident which took place during the last five years which may lead to a claim or suit in the future? If yes, please provide details on a separate page. Yes No NOTE: Any claims, suits or incidents that the applicant knew about or could have foreseen or discovered in a reasonable way prior to the effective date of coverage will be excluded from coverage. 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 claims containing any materially false information, or concealed 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 claims for each such violation. 09/07/01 5

Indicate any additional coverage needs, special remarks, or rating data not disclosed above (i.e. prescription drugs sold) C.

6 NOTICE TO APPLICANTS OF OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceal for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. Completion of this application does not bind coverage and does not guarantee issuance of a policy. SIGNED: Authorized Representative of the Applicant Date TITLE: Agent Information: Name: Address: Phone: ( ) C/R Sobel Use Only: 09/07/01 6

fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

HPL APP 01 11 15 Page 1 of 9

HPL APP 01 11 15 Page 1 of 9 HOSPITAL PROFESSIONAL LIABILITY APPLICATION NOTICE:=PROFESSIONAL=LIABILITY=AND=EMPLOYEE=BENEFITS=LIABILITY=COVERAGE=ARE=PROVIDED=ON=A=CLAIMS-MADE=BASIS.= OTHER=COVERAGE=WITHIN=THE=POLICY=MAY=BE=PROVIDED=ON=A=CLAIMS-MADE=OR=OCCURRENCE=BASIS.=PLEASE=REVIEW=THE=