Application FOR PHYSICIANS AND SURGEONS. Professional Liability Insurance

Application FOR PHYSICIANS AND SURGEONS Professional Liability Insurance

Home Office: 1800 Northern Boulevard Roslyn, New York 11576 T Telephone: (516) 365-6690 (800) 632-6040 Fax: (516) 365-7522 Rochester Office: 1200C Scottsville Road, Suite 195 Rochester, New York 14624 Telephone: (585) 328-8860 (800) 329-8860 Fax: (585) 328-8686

Home Office: 1800 Northern Boulevard Roslyn, New York 11576 T Telephone: (516) 365-6690 (800) 632-6040 Fax: (516) 365-7522 Rochester Office: 1200C Scottsville Road, Suite 195 Rochester, New York 14624 Telephone: (585) 328-8860 (800) 329-8860 Fax: (585) 328-8686

Home Office: 1800 Northern Boulevard Roslyn, New York 11576 A. GENERAL INFORMATION (Please type or print clearly in ink) If my application is approved, make coverage effective on / / (if possible) otherwise on any other date set by the Exchange. 1. Name: ( ) MD DO (Check One ) First Middle Last (Maiden) 2. Date of Birth: 3. Male Female 4. Social Security Number: I.R.S. Tax I.D. Number: 5. N.Y.S. License Number: Permanent Temporary List all non-n.y. S. Medical License (if applicable): a. c. State Lic.# Status State Lic.# Status b. d. State Lic.# Status State Lic.# Status If you have more than four non-n.y.s. licenses, explain in Remarks, #38. E.C.F.M.G. Number (if applicable): 6. Home Address: Telephone: (516) 365-6690 (800) 632-6040 Fax: (516) 365-7522 Rochester Office: 1200C Scottsville Road, Suite 195 Rochester, New York 14624 Telephone: (585) 328-8860 (800) 329-8860 Fax: (585) 328-8686 ( ) Number Street Telephone ( ) City County State Zip Fax 7. Mailing address (choose one): Home Primary Address (see question #8) Other (specify) (Explain in Remarks, #38.) ` B. PRACTICE LOCATIONS List all locations, other than hospitals and ambulatory surgery centers, at which you currently render professional services. Include all office locations, nursing homes, urgent care clinics, and other non-hospital locations. Attach additional pages as needed. 8. Primary Address for which coverage is desired: ( ) Number Street Telephone City County State Zip Fax This address is a (check one): Private Office Hospital Clinic Other

Number of hours per week you are at this location: Number of patients you see per week at this location: 9. Other Address of this Policy (if any): ( ) Number Street Telephone ( ) City County State Zip Fax This address is a (check one): Private Office Hospital Clinic Other Number of hours per week: Number of patients per week: If this policy is for more than two locations, indicate other location(s) in Remarks #38. 10. Privileges: a. List all hospitals and ambulatory surgery centers at which you are currently a staff member or to which you are applying for privileges. Attach additional pages as necessary. Total Hours Total Patients Facility No.1 Hospital Ambulatory Surgery Center Per Week You See Per Week Name City Privileges Active Type and Extent Pending Restrictions (if any) Total Hours Total Patients Facility No.2 Hospital Ambulatory Surgery Center Per Week You See Per Week Name City Privileges Active Type and Extent Pending Restrictions Total Hours Total Patients Facility No.3 Hospital Ambulatory Surgery Center Per Week You See Per Week Name City Privileges Active Type and Extent Pending Restrictions Do you want Certificates of Insurance provided to these facilities if and when your application is approved? YES NO All facilities listed, or Facility #1 Facility #2 Facility#3 b. If you do not have admitting privileges, please describe in detail your mechanism for handling your patients who may require immediate in-patient care.

C. TRAINING 11. Specialty: a. Medical Specialty Currently Practiced Sub-specialty b. Specialty for which you want coverage with PRI 12. Medical Education: M.D./D.O School Country Date 13. Postgraduate Medical Training: a. Internship From b. Residency: Specialty: Hospital To Address Dates City State Zip From Hospital Address To Dates City State Zip Explain any gaps in time from date of medical school graduation to completion of residency in Remarks #38. c. Fellowship From To Hospital Address Dates City State Zip 14, Board Certification: Are you American Board certified in your Specialty? YES NO Date Certified Are you American Board certified in your Sub-Specialty? YES NO Date Certified Are you American Board eligible in your Specialty? YES NO Date Eligible If Board Eligible, give date eligibility expires D. PROFESSIONAL AND INSURANCE HISTORY 15. Practice Locations List all locations at which you have practiced in the last ten (10) years. (Do not list training locations from Section C.) Explain any gaps in time and attach additional pages as needed. Name of Practice/Employer Address From To Mo./Yr Mo./Yr.

16. Prior Insurance Provide name(s) of professional liability carrier(s), policy number(s) and coverage period(s) of all professional liability insurance policies under which you have been insured in the past ten (10) years. If you are applying for Prior Acts Coverage, please complete the following for the entire Prior Acts Coverage Period. Attach additional pages as needed. Coverage Type of Period Insurance Medical Limits of Policy No. of From/To Carrier Policy # Specialty Liability CM/OCC Claims Do you currently have excess coverage through a hospital affiliation? YES NO 17. Insurance a. Have you ever practiced without insurance or allowed a Claims-Made policy to lapse without the purchase of Tail or Nose coverage? YES NO If yes, explain in Remarks, #38 b. Have you ever had professional liability insurance refused, declined, cancelled, or accepted on special terms? YES NO If yes, explain in Remarks, #38 c. Have you ever been required to pay an additional merit-rated premium or have you ever been involved in an appeal concerning the imposition of such a surcharge? YES NO If yes, explain in Remarks, #38 E. COVERAGE OPTIONS 18. Limits of Liability Please check the desired limits of liability: $500,000 per claim/$l,500,000 Annual Aggregate $1,000,000 per claim/$3,000,000 Annual Aggregate 19. Coverage Type. PRI offers both Claims-Made and Occurrence Coverage. A Claims-Made policy covers claims which arise and are made while the policy is in force. Occurrence Coverage protects you against any claim arising during your policy period irrespective of when the claim is reported. Select coverage type. Claims-Made Occurrence 20. Prior Acts a. Is this policy to replace an existing Claims-Made policy? YES NO b. Do you wish prior acts coverage (Nose) beginning on the initial issue date of your Claims-Made policy? YES NO c. Do you know of any claims, or incidents that may give rise to potential claims, for medical services you provided that occurred during the period for which Prior Acts coverage is desired, that have not been reported to the previous carrier of record? YES NO If yes, please explain: If yes, a Conversion Supplemental Application (E-104A) must accompany this application along with a copy of your most recent declarations page.

21. Scope of Coverage I am requesting coverage for my entire medical practice as described in this application. I do not want PRI coverage for the part of my medical practice listed below. Complete the following section to specify the part of your practice for which you do not want PRI coverage. Be sure to include the location and proof of coverage for the professional liability carrier providing coverage for that aspect of your practice. Practice/Location Carrier/Limits Dates Practice/Location Carrier/Limits Dates Practice/Location Carrier/Limits Dates 22. Discounts Are you currently receiving a premium discount as a result of having completed a New York State Insurance Department (NYSID) approved Risk Management Course with your present carrier? YES NO If yes, submit proof of completion of such course, including date discount became effective. F. MEDICAL CONDUCT INFORMATION 23. Governmental Action a. Has any government agency ever investigated, suspended, revoked, or taken any other action against either your narcotic license or your license to practice? YES NO If yes, explain in Remarks, #38 b. Have you ever been convicted of a crime? YES NO If yes, explain in Remarks, #38 24. Hospital Privileges Have you ever had privileges at any hospital or other institution reduced, revoked, restricted or suspended? YES NO If yes, explain in Remarks, #38 25. Health Do you have any health problem, illness or physical condition that impairs or could tend to impair your ability to practice your medical specialty? YES NO If yes, explain in Remarks, #38 If yes, please submit a letter from your treating physician addressing your state of health and whether any condition exists which could adversely affect the practice of your medical specialty 26. Claims or Suits Have you ever been named as a defendant in a malpractice claim or suit, with an incident date, report date or close date occurring within the last ten years, or are you presently involved in malpractice litigation? YES NO If yes, submit a separate form for each case in the last 10 years (See page 14)

G. PRACTICE ASSOCIATIONS REMINDER: Answers to the questions in this section should reflect your intended practice as of the date you wish this policy to become effective. 27. Practice Situation a. Indicate all practice situations that apply to you: Solo Physician Solo Medical Corporation Medical Corporation with more than one physician shareholder Medical Partnership Independent Contractor/Contractee Use of assumed name (DBA) Employed by another physician Employ another physician Other If you check any boxes above other than Solo Physician or Solo Medical Corporation, list below the name of the applicable entity(ies) and/or any physician(s). Attach copies of your letterhead(s), if any, to this application. Name of Entity (ies) Name of Physician Employer or Employee Professional Liability Insurance Carrier b. Do you wish coverage for any of the above entities? YES NO If yes, which one(s): If P.C. or partnership coverage is desired, please submit a copy of the Certificate of Incorporation, or Certificate of Partnership and filing receipt. 28. Other Physicians: Do you practice with other physicians not listed above? YES NO If yes, list the physician(s) with whom you practice and describe the association. Physician(s) Association 29. Other Medical Personnel a. List number and professional classification of any nurses or other ancillary staff you employ or lease: Number Classification Number Classification b. Is coverage desired? YES NO c. Do you employ any Physician Assistants and/or Nurse Practitioners and/or CRNA's and/or Nurse Midwives? YES NO If yes, list Type and Number Employed If you wish coverage for any P.A. and/or N.P. and/or CRNA, and/or Nurse Midwife, please contact this office for an application.

H. MEDICAL DIRECTOR AND TEACHING RESPONSIBILITIES 30. Additional Responsibilities Do you have any Medical Director or teaching responsibilities? YES NO If yes, complete the following questions (a-d). Attach additional pages as needed. a. Name of entity and location b. Your title c. Describe your responsibilities d. Does the entity provide you with coverage for: i) Your administrative responsibilities? YES NO ii) Your direct patient care? YES NO NOTE: Please be advised that coverage is not provided for any liability assumed solely as your role as medical director of any facility. However, coverage is provided for direct patient care. I. PRACTICE AND PROCEDURES: GENERAL QUESTIONS (To be completed by all applicants.) 31. Non-Hospital Births Do you provide direct patient treatment (not limited to obstetrical care) during delivery (including the immediate labor, puerperal and/or neonatal period) in any facility other than a licensed acute care hospital? YES NO If yes, give full details: 32. Termination of Pregnancy a. Do you perform termination of pregnancies? YES NO If yes, please provide the following information: # Performed Monthly Maximum Gestational Location at Each Location Age at Each Location Office Hospital Other b. List hospitals, clinics, or other facilities where you perform termination of pregnancies:

33. Non- Hospital Procedures a. Do you perform procedures in a non-hospital setting where anesthesia/sedation is administered? YES NO If yes, check type used: Spinal General Intravenous Obstetrical Caudal Local Intravenous Analgesia If yes: i) Location Surgicenter Office Other Non-Hospital Facility ii) Who administers the anesthesia? b. For Surgicenter or other Non-Hospital Facility, please provide the name and address of such. c. List the surgical procedures you perform in your office or other non-hospital facility: Procedure # Weekly Where Performed d. Do you have a protocol regarding pre-op clearance in the office or non-hospital setting? YES NO Is there a documented clinical evaluation pre-op by any of the following: YES NO Anesthesiologist CRNA Operating Surgeon e. Does a professional staff member monitor the patient post-op? YES NO Is this documented? YES NO f. Do you have formal discharge criteria? YES NO Does your discharge criteria require that a physician discharge the patient? YES NO g. Do you maintain a full emergency cart? YES NO i) Do you follow a protocol for checking the cart on a regular basis? YES NO ii) Are the checks documented? YES NO h. Do you maintain a written transfer agreement with a nearby hospital? YES NO 34. Weight Control a. Does your practice involve weight reduction or control, other than prescribing exercise? YES NO (Percentage of patients exclusively for weight reduction or control %) If yes, please explain fully including names of medication(s) prescribed or dispensed: b Do you solicit or advertise for weight control patients? YES NO If yes, submit copies of all advertisements.

c. Do you use Human Chorionic Gonadotropin (HCG) for weight control? YES NO d. Do you perform surgery for weight control? YES NO If yes, list all procedures performed: 35. Experimental and Investigative Procedures Are you currently treating or do you intend to treat any patient by means of an experimental, investigative or unconventional drug or therapy? YES NO If yes, indicate which of the following applies and attach a detailed, narrative outline or protocol and a copy of the patient consent form. Procedures: Use of experimental drug, device or material under U.S. Food and Drug Administration or other governmental agency investigational protocol and licensure. Other experimental, investigative or unconventional drug or therapy. 36. Changes In Practice Have your practice procedures/specialty, etc., changed in the past five years? YES NO If yes, please explain how the procedures/specialty, etc., have changed and give the dates of changes. J. PRACTICE AND PROCEDURES: SPECIALTY QUESTIONS FOR THE FOLLOWING SPECIALTIES, A SPECIALTY SPECIFIC ADDENDUM MUST BE COMPLETED: Anesthesiology Dermatology General Surgeons, Thoracic Surgeons, Vascular Surgeons Obstetrics and Gynecology Ophthalmology Orthopedic Surgery Otorhinolarnygology Pathology Pediatrics-Neonatology Physical Medicine & Rehabilitation Plastic Surgery Urology 37. OTHER SPECIALTIES Please check the category that most closely describes your practice. Major Surgery: Performing any operative procedure done under general, spinal or caudal anesthesia or assisting in "Major Surgery" on other than your own patients. Minor Surgery*: Performing any operative procedure other than as included in "Major Surgery" or assisting in "Major Surgery" on your own patients. No Surgery*: NOT performing any operative procedure included in "Major Surgery" or "Minor Surgery". *Note: Incising of boils and superficial fascia, suturing of minor lacerations and removal of superficial skin lesions are not considered operative procedures for the purposes of this application.

Interns, Family Practitioners, General Practitioners and Pediatricians Assisting in Major Surgery List Procedures: Where Performed: Chelation therapy (other than for the treatment of heavy metal poisoning) Chemotherapy Hypnosis Injection of Bursa Needle Biopsy (explain type): Peripheral Nerve Block Anesthesia Peritoneal Dialysis Polypectomy by Endoscopy Cardiovascular/Respiratory Angiograms Angioplasty: Coronary Any Other Bronchoscopy Cardiac Catheterization Left Heart Swan Ganz Permanent Pacemakers Temporary Pacemaker Stress Testing Umbilical Catheterization and Monitoring Vein Stripping Dermatological & EENT (Ear, Eye, Nose & Throat) Cryosurgery: Use of Nitrogen Any other compound: Excisional Punch Biopsy Foreign Body Removal from Eye Nasal Polypectomy Repair of Laceration not involving Nerve or Tendon Suction Lipectomy (submit proof of training) Gastro-intestinal Colonoscopy Duodenoscopy Esophagoscopy Gastroscopy Hemorroidectomy If yes, procedure performed Proctoscopy Sigmoidoscopy Neuro/Musculo-Skeletal Acupuncture (Please submit copy of NYS certification) Closed Reduction of Fracture Splinting or Casting of Non- Displaced Fractures Uro/Genital/GYN Aspiration of Cyst of Breast Breast Biopsy Cervical Biopsy Chorionic Villi Sampling Cervical Cautery Circumcision of Newborn Circumcision of Adult Culdocentesis D&C Endometrial Biopsy Hydrocelectomy Insertion of IUD Laparoscopic Assisted Hysterectomy Office Gynecology other than Pap Smears & Vaginal Exams Explain:

38. REMARKS Question # Answer Paragraph 44 of the Subscriber s Agreement provides for the return of a portion of the amount in the Subscriber's separate account which represents the Subscriber's share of the earnings of the Exchange during his/her term as a Subscriber. Such amount must be returned to the Subscriber after he/she is no longer insured by the Exchange. However, in instances where the Subscriber's premium will be paid by a person or entity other than the Subscriber, the Subscriber may agree in advance to assign such distribution and designate the person or entity which has paid the premium to receive such distribution by signing below and naming such recipient: Subscriber's Signature Date Name of Recipient

I do hereby warrant the truth of any statements and answers mentioned herein, and that I have not misrepresented or withheld any information which is calculated to influence the judgment of the Exchange in considering this application for professional liability insurance. AGREEMENT: I understand that the policy being applied for does not cover liability of others which I may have assumed under any contract or agreement, including PPO, HMO and all other managed care organizations. To assure proper protection I agree to submit a copy of such contract or agreement to the Exchange for underwriting consideration together with this application. The application form duly completed, together with any supplementary information, must be signed in ink by the applicant. Signature of the form does not bind the applicant or the Exchange to issue coverage. 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. Signature: (Applicants Signature) Date: PRINT NAME I understand that in order to underwrite professional liability insurance, The Exchange must have access to all possible information concerning my personal and professional life. I hereby authorize and direct any medical society, medical doctor, hospital, residency program, insurance company, underwriter, and insurance agent to furnish any information concerning me or my medical practice which the company may request. Since I understand that free exchange of information is essential, I agree that any person or organization furnishing information to the Exchange pursuant to this consent and direction, together with the agents, employees or officers of such person or organization will not be liable to me in any way for furnishing such information, even though the information is wrong. I understand and agree that, if I am approved as a Subscriber to the Exchange and a policy is issued to me, that there is a continuing obligation on my part to update and keep current all of the information furnished by me as part of this application. Signature: (Applicant's Signature) Date: PRINT NAME

CHECKLIST OF ATTACHMENTS TO APPLICATION You may use this list to review your need to enclose certain supporting documents. Unanswered questions and/or missing attachments may cause delay in processing the application: Not Attached Applicable Question # Supporting Document 20 E-104A Conversion Supplemental Application for Prior Acts coverage 20 Most recent Declarations Page 21 Proof of Coverage for Outside Practice 22 Proof of Risk Management Course Completion 25 Letter from Personal Physician 27a 27b 34b Copy of Letterhead Articles of Incorporation or Certificate of Partnership Copies of Advertisements 35 Narrative Outline or Protocol 35 Patient Consent Form 37 Copy of NYS Certification (Acupuncture) 37 Proof of Training (Suction Lipectomy)

Please make additional copies of this page, as necessary CLAIM INFORMATION 1. Name of patient 2. Age 3. Sex 4. Your relationship to patient (e.g. attending physician, primary surgeon, assistant surgeon, etc.): 5. Allegation: 6. Date of incident 7. Report date 8. Insurance carrier 9. Other defendants 10. Present stat Open claim Closed claim Date closed Settlement or Judgment Amount 11. Location of incident 12. Condition and diagnosis at time of incident 13. Dates and description of treatment rendered Condition of patient subsequent to treatment (and DATES OF FOLLOW-UP TREATMENT) I HEREBY DECLARE the above information is complete and true to the best of my knowledge and belief. Signed Date Signed CLAIM INFORMATION 1. Name of patient 2. Age 3. Sex 4. Your relationship to patient (e.g. attending physician, primary surgeon, assistant surgeon, etc.): 5. Allegation: 6. Date of incident 7. Report date 8. Insurance carrier 9. Other defendants 10. Present status Open claim Closed claim Date closed Settlement or Judgment Amount 11. Location of Incident 12. Condition and diagnosis at time of incident 13. Dates and description of treatment rendered 14. Condition of patient subsequent to treatment (and DATES OF FOLLOW-UP TREATMENT) I HEREBY DECLARE the above information is complete and true to the best of my knowledge and belief. Signed Date Signed

PHYSICIANS RECIPROCAL INSURERS NEW AND RENEWAL APPLICATION FOR EXCESS COVERAGE THIS FORM MUST BE COMPLETED BY THE PHYSICIAN AND SUBMITTED TO HIS/HER PRIMARY AFFILIATED HOSPITAL TO AVOID DELAYS IN PROCESSING OF THE APPLICATION NOTE: PRI PROVIDES EXCESS COVERAGE ONLY TO THOSE PHYSICIANS FOR WHOM IT PROVIDES PRIMARY MEDICAL MALPRACTICE COVERAGE Please check one: New Excess Policy Renewal Excess Policy 1. Name: 2. PRI Policy #: 3. Primary Affiliated Hospital: City/Town: 4. Excess Risk Management Program: (Mandatory for all new & renewal excess policies) Coursework completed*: When Taken/Completed? 5-Hour Program and Home Study Course *Please submit proof of completion if not taken with PRI 3-Hour Follow Up Program and Home Study Course With Whom/Where? (Questions 5 & 6 applicable to new excess policies only) 5. I wish coverage for Excess with PRI to be effective: 6. Name of present Excess carrier: I authorize and release of information, involving but not limited to claim matters, between my professional society or association, previous insurance carrier, hospital or clinic and Physicians Reciprocal Insurers AUTHORIZATION STATEMENT ( TO BE COMPLETED BY APPLICANT WHOSE PREMIUM FOR 1 ST LEVEL EXCESS LIABILITY INSURANCE IS BEING PAID THROUGH THE HOSPITAL EXCESS LIABILITY INSURANCE POOL). Assignment of certain rights by physician to hospital of primary affiliation with regard to excess professional liability (medical malpractice) insurance coverage. I hereby grant authority to (Name of Hospital of Primary Affiliation) To terminate, on my behalf, the excess liability insurance policy to be written from this application. In the event that this excess professional liability insurance is terminated or if I terminate such insurance for any reason, I hereby assign to this hospital all refunds of premiums, if applicable NOTE: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCEALING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIIVIL PENALITY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION Signature of Applicant Date of Signature TO BE COMPLETED BY HOSPITAL REPRESENTATIVE Physician is approved for Excess Coverage through this Hospital Yes No If no, explanation/reason: Name of Hospital Representative (Please print) Title of Hospital Representative Signature of Hospital Representative Telephone # ( ) Ext: Date