INDIVIDUAL APPLICATION FOR CLAIMS-MADE AND REPORTED DENTISTS PROFESSIONAL LIABILITY INSURANCE

Transcription

1 Home Office: Madison, Wisconsin Administrative Office: 8877 North Gainey Center Drive Scottsdale, Arizona INDIVIDUAL APPLICATION FOR CLAIMS-MADE AND REPORTED DENTISTS PROFESSIONAL LIABILITY INSURANCE The following are representations of facts known by you to be true. You agree that any coverage issued will be contingent upon the truth and upon final approval by National Casualty Company. If a policy is issued, this application will become part of the policy. Please fully complete this application, as an incomplete application cannot be evaluated. TO EXPEDITE THE EVALUATION PROCESS AND ALLOW US TO GET A RESPONSE BACK TO YOUR INSUR- ANCE BROKER AS QUICKLY AS POSSIBLE, PLEASE REMEMBER TO: (A) PLEASE PRINT IN INK OR TYPE AND FULLY COMPLETE THE APPLICATION. (B) PLEASE SIGN AND DATE THE APPLICATION. (C) PLEASE ANSWER ALL QUESTIONS UNLESS SPECIFICALLY INSTRUCTED OTHERWISE. (D) PLEASE PROVIDE THE REQUIRED DOCUMENTATION REQUESTED ON PAGE 7. (E) IF YOU ARE REQUIRED TO COMPLETE ANY SUPPLEMENTS, PLEASE BE SURE THAT ALL QUES- TIONS ON THOSE SUPPLEMENTS ARE ANSWERED AND THAT YOU SIGN AND DATE EACH SUPPLE- MENT. (SPECIFIC INSTRUCTIONS ARE ALSO PROVIDED ON EACH SUPPLEMENT.) I. ABOUT YOU 1. Name: 2. Date of Birth: 3. Social Security No.: 4. Professional Degree: DDS DMD Other: 5. Mailing Address: Street City County State Zip 6. Business Telephone No.: 7. Business Fax No.: 8. Residence Telephone No.: 9. Business Address: 10. Practice Web site Address: 11. Dental School: 12. Year Graduated: 13. Date You Began Practice: 14. Specialty School (if any): 15. Year Graduated: 16. Specialty: 17. Dental/Medical License Number(s) States(s) Expiration Date(s) DT-APP-4 (2-07) Page 1 of 6

2 18. Please provide the name(s) of your professional liability carrier(s) for the last three years, premium, policy number, limits and coverage dates. Also, please check if the policies were claims-made or occurrence types. Insurer Premium Policy No. Policy Limits Policy Period Type II. ABOUT THE PROPOSED POLICY Claims-Made Occurrence Claims-Made Occurrence Claims-Made Occurrence 19. Requested coverage effective date: Retroactive Date: 20. LIMITS OF LIABILITY DESIRED (Per Claim/Aggregate). Some limits are not available in certain states. $100,000/$300,000 $200,000/$600,000 $500,000/$1,500,000 $1,000,000/$3,000,000 $2,000,000/$4,000,000 $3,000,000/$3,000, Have you practiced without professional liability insurance in the last ten (10) years?... Yes No If Yes, explain in remarks section. 22. Has there been a professional liability claim or suit (settled or pending) made against you within the last five years?... Yes No If Yes, complete a separate Claim/Incident Supplement for each such claim or suit. 23. Within the past five years, have you had knowledge of any dental incident or activity which might give rise to a claim against you?... Yes No If Yes, complete a Claim/Incident Supplement for each matter and advise whether or not you have reported each matter to your professional liability insurance company. 24. Has any insurer canceled, declined, rescinded or modified coverage, or refused renewal?... Yes No If Yes, explain in remarks section. (Not applicable to Missouri applicants) 25. Has any governmental, peer review committee, hospital, professional association, patient or licensing agency ever investigated you, or suspended, revoked, placed on probation, reprimanded or taken any other action against you, your narcotics license or your license(s) to practice dentistry?... Yes No If Yes, provide a written explanation and attach a copy of the decree. 26. Do you have or have you had any physical disability or injury, personal health problems, including alcoholism, narcotics addiction or mental illness which affected your ability to practice dentistry?... Yes No If Yes, explain in remarks section and attach a current statement from your attending physician regarding your ability to treat patients. 27. Have you ever had complaints filed against you involving the administration of Medicare/Medicaid or patient insurance?... Yes No If Yes, explain in remarks section. 28. Are you an active member of your state dental association or an accredited dental association?... Yes No If Yes, please provide name of the association(s): DT-APP-4 (2-07) Page 2 of 6

3 III. ABOUT YOUR PRACTICE 29. As to your practice of dentistry, please complete the following: A. Do you practice as an employee or independent contractor with no ownership interest?... Yes No If Yes, please list below the locations where you work. The percentages must total 100. PLEASE COMPLETE IF YOU ARE AN EMPLOYED DENTIST OR AN INDEPENDENT CONTRACTOR. Legal Practice Name Owner(s) Address, including County Employee I/C Practice Time at Each Location B. Do you own your own practice?... Yes No C. Do you have ownership interest in more than one practice?... Yes No If Yes, how many practices do you own? D. If you own your own practice, do you also work as an employed dentist or independent contractor at another location?... Yes No If Yes, please complete the chart above for the non-owned location(s) and complete the Practice Ownership Supplement for the location you own. IF YOU ANSWERED QUESTIONS 29.B., 29.C. OR 29.D. YES, PLEASE COMPLETE THE PRACTICE OWN- ERSHIP SUPPLEMENT. 30. Do you share dental facilities with another dentist other than your partners, corporate officers, employees or independent contractors?... Yes No If Yes, please attach proof of dentists professional liability insurance for the other dentist(s) in that facility sharing arrangement (copies of current Declarations Pages or current Certificates of Insurance will suffice). 31. Do you have a contract to provide dental services with a hospital, clinic or other commercial or charitable entity (other than a private dental practice)?... Yes No NOTE: Please provide a copy of all such contracts. 32. Total number of hours YOU practice per week at all locations: If you practice twenty (20) hours or less per week on average: a. What date did you begin this schedule? / / b. When do you expect to begin practicing over twenty (20) hours per week on average? 33. Number of patients YOU treat per month: 34. What percentage of those patients are under age sixteen (16)? Are you a full-time student enrolled in an accredited dental post-doctoral program?... Yes No 36. Are you a full-time dental school faculty member?... Yes No If Yes, please provide name of school: 37. Have you taken a Risk Management Course or Seminar during the last three years?... Yes No If Yes, please provide a copy of certificate or transcript for a possible credit. DT-APP-4 (2-07) Page 3 of 6

4 IV. OFFICE PROCEDURES 38. What type of informed consent do you use? Oral Written None If oral, is chart noted, dated and initialed by the patient?... Yes No If written: a. Who reviews the consent form with the patient prior to treatment? b. Is the consent form available in the patient s language if the patient does not speak English?... Yes No 39. Do you obtain a complete patient medical history?... Yes No 40. How often do you or your staff update patient histories? Each visit Occasionally No policy If occasionally, what is your procedure? Do the answers to the above questions 39. and 40. apply to all locations where you practice?... Yes No If No, please explain on a separate sheet or in the remarks section. Anesthesia/Analgesia: 41. Are patients treated in your office with: a. Local anesthesia?... Yes No b. Nitrous oxide?... Yes No c. Chloral Hydrate?... Yes No d. Oral Premeds?... Yes No If Yes, who administers this anesthesia? You Another dentist Anesthesiologist or CRNA 42. Are patients treated in your office under conscious sedation?... Yes No If Yes : a. Who administers the anesthesia? You Another dentist Anesthesiologist or CRNA b. Is it administered via I.V. or I.M.?... Yes No c. If administered by another dentist, is the dentist licensed to provide anesthesia?... Yes No d. Is this dentist YOUR employee?... Yes No e. If administered by an Anesthesiologist or CRNA, is that person YOUR employee?... Yes No 43. Are you treating patients who are under general anesthesia/deep sedation?... Yes No If Yes, where are the procedures performed? In your office In a hospital or surgical center a. If In your office, who administers the anesthesia? You Another dentist Anesthesiologist or CRNA b. Is it administered via I.V. or I.M.?... Yes No c. If administered by another dentist, is the dentist licensed to provide anesthesia?... Yes No d. Is this dentist YOUR employee?... Yes No e. If administered by an Anesthesiologist or CRNA, is that person YOUR employee?... Yes No IF I.V., I.M. OR GENERAL ANESTHESIA IS USED, YOU MUST COMPLETE THE ANESTHESIA SUPPLEMENT. V. ABOUT YOUR PROCEDURES 44. Are you a: General Dentist or Specialist If you are a Specialist, please list Specialty: Specialty training: If you are a Specialist and also perform procedures in another area of dentistry, please specify the area(s) and please estimate the time spent practicing in these areas: DT-APP-4 (2-07) Page 4 of 6

5 45. DURING A TYPICAL PRACTICE MONTH, WHAT PERCENTAGE OF YOUR TIME IS DEVOTED TO EACH OF THE FOLLOWING PROCEDURES? (PERCENTAGES SHOULD ADD UP TO 100) a. Diagnostic (exams, X-rays, etc.):... b. Preventive (fluoride, prophylaxis, patient education, pit and fissure sealants, etc.):... c. Restorative (single-unit restorations):... d. General services (patient management):... e. Prosthodontic (fixed and removable multi-unit restorations):... f. Endodontics:... g. Periodontics:... h. Pedodontics:... i. Orthodontics:... j. Treatment for TMJ/TMD:... k. Oral Surgery: If YOU show a percentage in the Oral Surgery item 45.k. above, please specify which procedure(s) you perform: Simple extractions Third molar extractions (please specify type(s) below) Amount of monthly practice time:... Soft tissue impactions Partial bony impactions Total bony impactions Describe any other surgical procedures YOU perform, including surgical periodontic procedures: Amount of monthly practice time for these other surgical procedures: Do you currently use paraformaldehyde or heavy-metal Sargenti type compounds in any dental procedure?... Yes No Have you ever used paraformaldehyde or heavy-metal Sargenti type compounds in any dental procedure?... Yes No If Yes, when did you last use it? 48. Do you provide any restorative or surgical implant services?... Yes No If Yes, please complete Implant supplement. 49. Do you perform TMJ/TMD procedures?... Yes No If Yes, please complete TMJ/TMD supplement. 50. Do you use lasers?... Yes No If Yes, please complete laser supplement. VI. REMARKS SECTION (please indicate question number to which your response pertains) DT-APP-4 (2-07) Page 5 of 6

6 VII. APPLICANT S STATEMENT/SIGNATURE I understand that this application is for a Dentists Professional Liability Insurance Policy and is subject to acceptance by the insurance company. I understand that I must immediately report any claim or potential claim to my insurance representative or directly to the Company. Important notice: Your agent can provide a copy of the policy form for you to evaluate. For complete and specific details of Coverage, conditions, limitations and exclusions, be sure to read the policy, including any attachments to it. I understand that any policy issued will rely on the truth of the statements and representations I have made herein and that misrepresentations that are fraudulent, or such that the Company would not have issued the policy if the true facts had been known, may result in a denial of coverage for any claim which may be made under this insurance. I understand that by completing and submitting this application for insurance, I am also applying for membership in the Dental Professionals Purchasing Group, a risk purchasing group formed for the sole purpose of providing professional liability insurance to dentists. My sole purpose in becoming a member is to purchase professional liability insurance. FRAUD WARNING: 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. FRAUD WARNING (Applicable in Tennessee and Washington): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Applicant s Signature Date Agent Name: Agent License No.: (Applicable to Florida Agents Only) Iowa Licensed Agent: (Applicable to Iowa Agents Only) COMPLETION OF THIS FORM NEITHER BINDS COVERAGE NOR GUARANTEES A POLICY WILL BE ISSUED. Please attach a copy of: Your current insurance Declarations page including retroactive date. Certificate or Transcript evidencing completion of risk management course or seminar within the last three years for possible premium credit (if you answered Yes to question 37.). Your practice letterhead. Contracts, if any, with hospitals, clinics or any commercial or charitable entity other than a private dental practice (if you answered Yes to question 31.). Evidence of dentists professional liability insurance for: a. your co-owners (per the PRACTICE OWNERSHIP SUPPLEMENT ). b. your employee dentist(s) and/or the independent contractor dentist(s) in your practice (per the PRAC- TICE OWNERSHIP SUPPLEMENT ). c. dentists in office-share arrangements (if you answered Yes to question 30.). Please note that exclusions may apply. Read your policy carefully. DT-APP-4 (2-07) Page 6 of 6