ANCILLARY APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE MIDWEST MEDICAL INSURANCE COMPANY 7650 EDINBOROUGH WAY, SUITE 400, MINNEAPOLIS, MN 55435-5978 PH. (952)838-6700 or 1-800-328-5532 FAX (952)838-6808 PLEASE TYPE OR PRINT CLEARLY ALL RESPONSES AND ANSWER ALL QUESTIONS. COVERAGE WILL NOT BE CONSIDERED UNTIL THIS APPLICATION IS COMPLETE. I. AGENT (Do not complete this section if you are insured directly with MMIC) Agent Name Agency Name Address City State Zip Phone Number Fax Number II. NAME AND ADDRESS A. Client Information First Name Middle Name Last Name Title (CRNA, DPM, etc) Date of Birth Male Female Social Security Number License # BNDD (DEA) # Home Address City State Zip County Home Telephone Fax Number Email Address B. Please list all office locations where you currently practice. List principal location first. 1. Employer Name and Address City State Zip County Employer Telephone Fax Number Email Address 2. Employer Name and Address City State Zip County Employer Telephone Fax Number Email Address C. Please list all hospitals where you currently practice. List principal location first. 1. Hospital Name Hospital Address City State Zip County Hospital Telephone Fax Number 2. Hospital Name Hospital Address City State Zip County Hospital Telephone Fax Number D. Billing Information Billing Address City State Zip County E. Effective Date of Coverage Insurance coverage effective date to commence at 12:01 a.m. on: Month Date Year AncApp Page 1 of 5 03/00
III. PROFESSIONAL LIABILITY COVERAGE Limits of Liability Desired (Limits indicated are per claim and annual aggregate) $1,000,000/$3,000,000 $3,000,000/$5,000,000 $5,000,000/$7,000,000 $2,000,000/$4,000,000 $4,000,000/$6,000,000 Other-Specify $200,000/$600,000(NE only) A. Most Recent Insurance Carrier Policy Number B. I am applying for retroactive coverage Yes Retroactive Date: If Yes, you must attach a copy of your most recent declarations page from your present carrier indicating the original effective date of coverage and the current expiration date. IV. SPECIALTY SECTION ONE (Check your specific professional occupation.) ( ) Chiropractor ( ) Nurse Practitioner ( ) Physical Therapist-Employed ( ) Chiropractor Assistant ( ) Occupational Therapist ( ) Physical Therapist-Owner ( ) Dental Hygienist ( ) Occupational Therapist-Aide ( ) Physical Therapy-Assistant ( ) Dentist ( ) Operating Room Technician ( ) Physician/Surgeon Assistant ( ) Dietician or Nutritionist ( ) Optician ( ) Physicist or Biologist ( ) EEG/EKG Technician ( ) Optometrist ( ) Cert. Registered Nurse Anesthetist ( ) Laboratory Supervisor or Director ( ) Optometry-Assistant ( ) Podiatrist ( ) Medical Office Assistant ( ) Oral Surgeon ( ) Psychologist ( ) Medical Technician ( ) Orthotist/Prothetist ( ) Respiratory Therapist ( ) Midwife ( ) Paramedic/EMT ( ) Respiratory Therapist-Aide ( ) Nurse ( ) Perfusionist ( ) Social Worker ( ) Nurse Aide/Homemaker ( ) Pharmacist ( ) X-ray Technician ( ) Pharmacy Assistant ( ) * Other * If other is checked, provide a brief description of your duties. (Supplemental information or advertising material available explaining duties should be included.) SECTION TWO Telemedicine Do you practice across state lines? Please describe equipment used: Yes No If yes, which states? Approximate annual number of telemedicine encounters? Please state types of encounters: V. MEDICAL EDUCATION A. Check the highest level of education you have completed relating to practice in your field: ne required Baccalaureate Degree Post-Doctorate Degree Diploma Masters Degree Other Associate Degree Doctorate Degree B. How many hours have you completed in any continuing education for your field of practice within the last 3 years? Hours: C. Additional Training: Type: Dates: Type: Dates: AncApp Page 2 of 5 03/00
VI. UNDERWRITING AND RATING INFORMATION A. Indicate what kind of organization you are a member of and give names of other members and services they provide. ne Partnership P.A. P.C. Other If other is checked, please explain: Name of Member or Partner Services 1. 1. 2. 2. 3. 3. B. Name of professional corporation, association or other organization: Retroactive Date: C. Is separate limit of liability desired for entity? Yes D. Do you prescribe drugs? Yes Do you perform surgical procedures? Yes E. If you are a member of any state patients compensation fund, please indicate state(s): Indicate work hours per week : Note: You, your partners or members of your P.A. or P.C. must be covered together. Please complete an application for each partner or member of the P.A. or P.C. VII. INFORMATION ON PROFESSIONAL EMPLOYEES. A. If you have professional employees, list job categories and number of employees for each: Job Categories Count Job Categories Count 1. 2. 3. B. For your employees, please indicate one of the following: Employees are to be covered individually. (Policy limits apply individually and separate applications are required.) Employees are to be covered as additional insureds. (Policy limits are shared.) coverage for employees. C. Do employees carry their own professional liability insurance? Yes D. Do you require your employees to carry minimum professional liability insurance limits? Yes Limits Required: $ E. Do you require proof of insurance? Yes F. If you have independent contractors working for you, please describe. Including type and in what capacity the independent contractor is working: Number of Contractors: Total hours per month worked by all contractors: G. Do you require the independent contractor to carry their own professional liability insurance? Yes Limits Required: $ H. Do you require proof of insurance? Yes AncApp Page 3 of 5 03/00
VIII. BACKGROUND/PRACTICE PROFILE A. Where have you practiced your profession since completion of your formal training? (Including military or any public service organization.) City State County From: Mo./Yr. Year: Mo./Yr. City State County From: Mo./Yr. Year: Mo./Yr. City State County From: Mo./Yr. Year: Mo./Yr. B. List the states in which you are currently licensed to practice your profession: C. List medical societies and professional organizations in which you are currently a member. Are you board certified? Yes Name of Board: NOTE: If any of the answers to questions D through N are yes, details must be provided in the REMARKS section of this application. D. Has any revocation, suspension or other change in status occurred with respect Yes No to your license to practice, your BNDD (DEA) license, your privileges or participa- ( ) ( ) tion at or with any hospital, health maintenance organization, or other medical facility, or your certification or membership by or in any medical association, medical society or medical board? Yes No E. Are you aware of any complaint or investigation with respect to your license to ( ) ( ) practice, your BNDD (DEA) license, your privileges or participation at or with any hospital or other medical facility? F. Has any hospital, medical association, medical society or medical board, health ( ) ( ) maintenance organization, licensing authority or peer review organization notified you of its intention to consider imposing any such change of status, privileges, participation, certification or membership? G. Have you been treated for alcoholism, narcotics addiction or mental illness? ( ) ( ) (If yes, please accompany this application with a letter of treatment outlining dates of treatment, success of treatment and current status. This letter should be from your treating physician or institution. Also include a letter from your PSP or AA sponsor verifying attendance.) H. Have you become aware of any chronic illness or physical defect that ( ) ( ) impairs or could tend to impair your ability to practice your specialty? (If yes, please accompany this application with a letter of treatment outlining dates of treatment, success of treatment and current status. This letter should be from your treating physician or institution.) I. Do you have any contagious disease or other condition that requires you or ( ) ( ) your physician to report to the Department of Health? J. Have you ever been convicted of a felony? If yes, give details (including dates). ( ) ( ) K. Has any insurer cancelled, declined coverage, refused renewal, or modified ( ) ( ) coverage (i.e. reduced limits, assigned a deductible, restricted coverage, surcharged rates) on an individual basis for any similar insurance? If yes, explain why and give name of carrier(s): L. Are you in active military service? ( ) ( ) AncApp Page 4 of 5 03/00
M. Are you employed by a state, federal, or local public entity? ( ) ( ) N. CLAIM INFORMATION (Failure to provide complete information as requested will cause delay in processing your application.) Has any professional liability claim or suit been brought against you within the ( ) ( ) past 10 years? If yes, how many? Please complete (for each prior claim/suit) the Prior Claim/Suit Information Addendum attached, which forms a part of this application. (For reporting more than two claims, use photocopies of the Prior Claim/Suit Information). Question Number REMARKS I hereby certify that the foregoing information is true and correct; I authorize access by, and release to, Midwest Medical Insurance Company of any and all information pertaining to underwriting the undersigned applicant and relating to medical claims or any other matter in the possession, custody or control of any of the following: State Board of Medical Examiners or Medical Practice; or any other medical association or medical organizations; any county medical society or medical organization; any insurance carrier that previously has insured or been requested to insure the undersigned applicant with respect to medical professional liability and/or premises liability coverage; and any other peer review committee or organization reviewing professional conduct on behalf of any hospital, health maintenance organization or third party, private or public, reimburser, including Minnesota/North Dakota/South Dakota/Wisconsin/Iowa/Nebraska/Illinois Departments of Welfare. Midwest Medical Insurance Company agrees to hold in confidence, use only for its proper business purposes and, unless otherwise constrained by law, not to re-release to third parties any and all information concerning applicant which comes into its possession. Applicant acknowledges that it is within the proper business purposes of Midwest Medical Insurance Company to discuss any such information within its committees and boards and to communicate conclusions relating thereto to applicant and administrative or executive personnel of his employer or prospective employer. Signing this application does not bind the Company to complete the insurance. All information requested in this application is considered material and important. If the Company agrees to be bound under the terms of this application, your policy is void if you hide any important information from us, mislead us, or attempt to defraud or lie to us about any matter contained in this application. I certify that any and all claims or potential claims against me, of which I am aware, have been reported to my current professional liability carrier. Date Applicant Signature AncApp Page 5 of 5 03/00
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