231 South Bemiston, Suite 1000 St. Louis, MO 63105 Email: submissions@galeninsurance.com LOCUM TENENS NEW BUSINESS APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE CLAIMS MADE COVERAGE INFORMATION REQUIRED CHECKLIST Please submit the following, along with the other information requested in this application: 1. Copy of all licenses and/or certifications 2. Curriculum Vitae 3. Authorization for release of information signed by applicant 4. Completed Form A Claim/Incident Report for all claims, suits, and incidents in the past 10 years. (If none, then mark NONE and sign) 5. Copy of current Insurance Declarations page INSTRUCTIONS TO APPLICANT 1. Answer all questions; if a question is not applicable, state N/A, PLEASE TYPE OR PRINT LEGIBLY 2. If space is insufficient to answer any question fully, attach a separate sheet 3. The application must be signed and dated by the applicant 4. If the answer to any question is none, state None IMPORTANT INFORMATION THIS DOCUMENT IS NOT A BINDER OR ACCEPTANCE OF INSURANCE Insurance coverage will not be considered until this application is completed, signed and dated. Failure to provide complete information and attachments as requested will cause delay. Completion of this form, with or without payment of premium, does not bind Galen Insurance Company ( Company, or we or us ) to issue insurance. A policy of insurance is issued in reliance of the Applicant s complete and truthful information, provided in this application. False, misleading, and/or any material misrepresentation of any information provided by the Applicant may result in cancellation of the policy or a recalculated premium during the underwriting period. The insurance policy is subject to a 45 day underwriting period beginning on the effective date of coverage. Galen Insurance Company may cancel the policy within the underwriting period if the risk does not meet its underwriting standards provided notice of cancellation is sent to the insured at least 15 days prior to cancellation. If the Company discovers a material risk factor during the underwriting period, then the insurer shall recalculate the premium provided the risk continues to meet its underwriting standards and notice of the recalculated premium is sent to the insured. This document is an application for a claims-made policy of professional liability insurance. If issued, coverage under the policy is limited to liability for those claims that: (a) arise from incidents or events that happen while coverage under the policy is in force and that involve a named insured s professional services; and (b) are first made against a named insured and are reported to the Company during the policy period, including any extended reporting period, or during any optional extended reporting period provided through an endorsement. INSURANCE COVERAGE IS SUBJECT TO UNDERWRITING APPROVAL, AND FULL PAYMENT OF THE PREMIUM. NO COVERAGE EXISTS UNTIL THE PREMIUM IS FULLY PAID AS AGREED AND A DECLARATION PAGE, TOGETHER WITH ANY ENDORSEMENTS THAT MAY APPLY, HAS BEEN ISSUED TO THE POLICYHOLDER. For Agent s Use Only Agent s Name Agency Name Agent s Name Agency Name Date Phone Page 1 of 5
231 South Bemiston, Suite 1000, St. Louis, MO 63105 Email: submissions@galeninsurance.com LOCUM TENENS NEW BUSINESS APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE CLAIMS MADE COVERAGE 1. APPLICANT INFORMATION a. Full Name: (Include all names by which you have been known, and dates during which the name was used) b. Date of Birth: SS#: Male Female c. MD DO Other: Medical License No.: d. Are you employed by an agency? If yes, please list name: 2. COVERAGE INFORMATION a. Name of Galen physician/surgeon you are substituting for: b. Galen physician/surgeon policy Number: c. Dates of Locum Tenens Service: from 12:01 a.m. to 12:01 a.m. d. Do you currently have malpractice insurance coverage which extends to your individual professional activities performed while acting for and on behalf of the above-named physician/surgeon? If yes: Policy Number Policy Effective Date Policy Expiration Date e. Location of current full-time practice activities: f. Do you practice in other states? If yes, what percentage of your practice is in other states? % 3. MEDICAL EDUCATION/BACKGROUND a. What is your medical specialty?: Sub-Specialty?: b. Are you board certified? If yes, list board certifications and date certified. Certification Date Certified (M/Y) 1. 2. c. Medical School: Year of completion: Degree: Page 2 of 5
d. Internship location: (Name of Hospital) e. Residency Location(s) Name of Hospital: Name of Hospital: f. Additional Training/Fellowship (Name of Hospital/Facility): 4. CLAIMS INFORMATION a. Do you have any open/pending malpractice claims or suits filed against you? b. Have you had any malpractice claims/suits/incidents filed against you, settled, dismissed or discontinued within the past ten (10) years? If YES to either question above, please complete the Claim/Incident Report. 5. ADDITIONAL PROFESSIONAL INFORMATION a. During the past year, have you incurred or become aware of having an illness or physical disability that impairs or could impair your ability to practice your medical specialty? If YES, a statement from your physician attesting to your fitness to practice your specialty must accompany this application. b. Have you been investigated, charged with, or convicted of any crime other than minor traffic violations? c. Have you ever been the subject of disciplinary of investigative proceedings by a governmental or administrative agency, hospital or professional association? d. Have you had your privileges or license either voluntarily or involuntarily revoked, suspended, restricted or subject to a reprimand, placed on probation? e. Have you ever been accused/treated for alcoholism or drug addiction, mental illness, or sexual misconduct of any kind? f. Has any insurer ever cancelled, declined, refused to renew or only accepted on special terms your professional liability insurance? Page 3 of 5
6. ACKNOWLEDGEMENTS, AUTHORIZATION AND SIGNATURE a. I hereby declare that, to the best of my knowledge and belief, all the statements in this application, including any supplemental materials, are true and correct and I have not knowingly withheld any information which is calculated to influence the judgment of Galen Insurance Company in considering this application for professional liability insurance. I understand that any material misrepresentation in this application which Galen Insurance Company relies on to its detriment may result in cancellation of the policy during the underwriting period. b. I hereby authorize Galen Insurance Company to obtain full information from any person or insurance companies with respect to any claim or suit pertaining to professional acts or omissions asserted against me. I further authorize and consent to the release of information by a hospital/facility, its medical staff, medical associations or licensure board on request regarding any information they may have concerning my staff privileges and/or licensure. FRAUD DISCLOSURE STATEMENT Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Signature of Applicant Date Page 4 of 5
Form A Claim/Incident Report Please complete for each suit, claim, or incident for which you responded yes in questions c-e of the application. 1. Name of Patient: Age: Sex: 2. Your relationship to patient: (e.g. Attending Physician, Primary Surgeon, Assistant Surgeon) 3. Type: Incident Request for records Demand for money or services Suit 4. Allegation(s) (as stated by patient/plaintiff): 5. Date of Incident: Date Notified: Date Reported to Insurer: 6. Name of Insurer: 7. Location, State, and County of Incident: 8. Other Defendants involved: (Physicians, Professionals or Entities) 9. Condition/diagnosis at time of Incident: 10. Dates/description of treatment rendered: 11. Condition of patient subsequent to treatment: 12. Did you in any way alter, embellish, delete, change, and/or destroy any records, medical or otherwise, or were allegations made that you did so, pertaining to this claim? 13. Status of claim: Suit threatened, no action taken Court outcome in your favor Open Status Pending Suit filed but dropped by claimant jury verdict Summary judgment in your favor directed verdict Awaiting mediation/arbitration Settled out of Court Court outcome in favor of plaintiff Awaiting Court action Date Claim paid: jury verdict Reserve Amount:$ Amount paid on directed verdict your behalf: $ verdict amount:$ Did you wish settlement of the claim? 14. Name and address of the Attorney assigned to your case: 15. Name of Plaintiff s Attorney: I understand this information becomes a part of my application for professional liability insurance. Print Name: Signature: Date: Page 5 of 5