TOI: 11.2 Med Mal-Claims Made Only Sub-TOI: Chiropractic

Transcription

1 Project Name/Number: / Filing at a Glance Company: Philadelphia Indemnity Insurance Company SERFF Tr Num: PHLX- State: Wisconsin G TOI: 11.2 Med Mal-Claims Made Only SERFF Status: Closed-Filed State Tr Num: Sub-TOI: Chiropractic Co Tr Num: State Status: Filing Type: Form Reviewer(s): Rebecca Rebholz Author: SPI PhiladelphiaIndemnity Disposition Date: 06/26/2012 Date Submitted: 06/25/2012 Disposition Status: Filed Effective Date Requested (New): 07/30/2012 Effective Date (New): Effective Date Requested (Renewal): Effective Date (Renewal): General Information Project Name: Status of Filing in Domicile: Project Number: Domicile Status Comments: Reference Organization: Reference Number: Reference Title: Advisory Org. Circular: Filing Status Changed: 06/26/2012 State Status Changed: Deemer Date: Created By: SPI PhiladelphiaIndemnity Submitted By: SPI PhiladelphiaIndemnity Corresponding Filing Tracking Number: Filing Description: Philadelphia Indemnity Insurance Company previously introduced and received approval for Chiropractors Professional Liability Coverage forms and endorsements in your state. We are now filing a Supplemental Claims Information Application form to be completed by every applicant for coverage under this program. This application provides details of previous claims, including the date of the claim and whether it is still open or closed. A separate application form is to be completed for each claim or incident. A copy of the application is enclosed for your review. 1) Malpractice Insurance - Chiropractic Professional Liability Application - Supplemental Claim Information Form # PI- CPHC-CLAIM 05/12

2 Project Name/Number: / This application is completed by the insured; the information supplied in the application becomes a part of the policy. State Narrative: Company and Contact Filing Contact Information Diane Quarles, Compliance Analyst One Bala Plaza [Phone] Suite [FAX] Bala Cynwyd, PA Filing Company Information Philadelphia Indemnity Insurance Company CoCode: State of Domicile: Pennsylvania One Bala Plaza Group Code: 3098 Company Type: Suite 100 Group Name: Philadelphia State ID Number: Insurance Companies Bala Cynwyd, PA FEIN Number: (610) ext. [Phone] Filing Fees Fee Required? Retaliatory? Fee Explanation: Per Company: No No No

3 Project Name/Number: / Correspondence Summary Dispositions Status Created By Created On Date Submitted Filed Rebecca Rebholz 06/26/ /26/2012

4 Project Name/Number: Disposition / Disposition Date: 06/26/2012 Effective Date (New): Effective Date (Renewal): Status: Filed Comment: Rate data does NOT apply to filing.

5 Project Name/Number: / Schedule Schedule Item Schedule Item Status Public Access Supporting Document Appraisal or Arbitration Provision Filed Yes Supporting Document Certification of Compliance and Filed Yes Readability Form Chiropractic Professional Liability Application Supplemental Claim Information Filed Yes

6 Project Name/Number: Form Schedule / Schedule Item Status Filed Form Name Form # Edition Chiropractic 06/26/2012 Professional Liability Application Supplemental Claim Information CLAIM Date Form Type Action Action Specific Data Readability Attachment 05/12 Application/ New Application - Binder/Enro Chiropractic llment Claim Supplement al - Countrywide PI-CPHC- PI-CPHC- APP CW (05-12) (2).PDF

7 Malpractice Insurance Chiropractic Professional Liability Application SUPPLEMENTAL CLAIM INFORMATION Submit one form for each claim or incident. If space is insufficient to answer any question completely, please use the Additional Information page attached to this application. 1. Full name of the Applicant 2. Full name of the Entity which reported the claim (if different from above): 3. Full name of the claimant: 4. Indicate whether: Claim / Suit Incident / Potential Claim 5. Date / Period of alleged error: 6. Date the claim was reported to the insurance carrier: 7. Other parties against which this claim is made: 8. This claim is: Open Closed 9. If CLOSED, indicate the date closed: 10. Please complete the following: If claim is still open: a. Claimant s settlement demand: $ b. Defendant s offer for settlement: $ c. Insurance company s loss reserve: $ d. Deductible: $ e. Total loss and expenses paid to date: $ If claim is closed: a. Loss paid in excess of deductible: $ b. Expenses paid in excess of deductible: $ c. Deductible: $ d. Settlement reached via: Court Judgment Formal mediation/arbitration proceeding Out of court settlement Note: If information is not available, please provide a copy of the suit papers. 11. Name of Insurance company: 12. Claim number: 13. Description of claim / incident: Chiropractor Professional Liability PI-CPHC-CLAIM 05/12 Page 1 of Philadelphia Insurance Companies

8 a. Provide a full description of the claim/incident. Please include the events that lead up to the claim, nature of the alleged injuries sustained against you or your Corporation, limited liability company or limited liability partnership and any allegations made against you in which you worsened the condition. b. Is this claimant a patient you have treated in the past? If no, fully explain claimant s relationship c. Is there documentation within the patient s file of their medical history and your treatment plan? Yes No d. What actions have you taken to prevent a recurrence of such a claim in the future? Yes No I understand that the information submitted herein becomes a part of my Philadelphia Insurance Companies Cover-Pro sm Healthcare application and is subject to the same conditions as stated on the application. Name (Please Print/Type) Title ( ) Signature Date The above signed warrants that he/she is authorized and has the power to complete and execute this Application, including the Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other insured persons. Produced By: (Section to be completed by Producer/Broker) Producer Agency Producer License Number Agency Taxpayer ID or SS Number Address (Street, City, State, Zip) Chiropractor Professional Liability PI-CPHC-CLAIM 05/12 Page 2 of Philadelphia Insurance Companies

9 ADDITIONAL INFORMATION This page may be used to provide additional information to any question on this application. Please identify the question number to which you are referring. Signature Date Chiropractor Professional Liability PI-CPHC-CLAIM 05/12 Page 3 of Philadelphia Insurance Companies

10 Project Name/Number: Rate Information / Rate data does NOT apply to filing.

11 Project Name/Number: / Supporting Document Schedules Item Status: Status Date: Bypassed - Item: Appraisal or Arbitration Provision Filed 06/26/2012 Bypass Reason: n/a Comments: Satisfied - Item: Certification of Compliance and Readability Comments: Attachment: PDF Item Status: Status Date: Filed 06/26/2012

12 CERTIFCATE OF COMPLIANCE AND READABILITY I Alan Eife, (name), an officer of Philadelphia Indemnity Insuranclÿ (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. clauses. 2. The form(s) does(do) not contain any inconsistent, ambiguous, or misleading 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 currenfiy on file with the commissioner of insurance and the only unconventional policy provisions are clearly marked or otherwise indicated pages 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:

13 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..,., S'iÿt u re) AVP (Title) 6ÿ Individual responsible for this filing: Name: Diane Quarles Title: State Filing Anlayst Address: One Bala Plaza, Suite 100 Bala Cynwyd PA Phone Number: (610) Date: 06/18/12