Professional Liability Insurance Application Specified Medical Professionals (Coverage Issued on a Claims-Made Basis) Applicant s Instructions: 1. Answer all questions. If a question is not applicable, state NOT APPLICABLE. 2. If space is insufficient to answer any questions fully, use last page or attach separate sheet. 3. Application must be signed and dated by owner, partner, officer or administrator. 4. If the answer to any question is none, state NONE. 5. Please do not complete application earlier than 45 days before proposed effective date of coverage. (PLEASE TYPE OR PRINT IN INK) PART I (To be completed by all applicants): 1. (a) Full Name of Applicant (Include professional degree/license if applicant is individual): License #: (b) Business Phone: Fax: Home Phone: (c) Applicant s Date and Place of Birth, or Date Established: 2. (a) Principal Business Address: (Attach list of any additional locations): No. Street Town County State Zip Code (b) Square feet of total office space (all locations): 3. (a) Applicant is: Self-employed individual (unincorporated) Professional Corporation (for profit) Self-employed individual (incorporated) Professional Corporation (non-profit) Partnership Employee of: Professional Association (Give name of employer) Other (Describe): (b) The business, corporation or partnership name is: (c) Give names of all partners or members of the firm who provide professional services: (d) Attach a copy of letterhead or other business stationery. In what states is the applicant registered and licensed to practice? (if none, attach explanation) 4. (a) Indicate applicant s professional specialty(ies) (CHECK ALL THAT APPLY): Chiropractor Laboratory Technician Optician Psychologist Counselor (describe) Medical Personnel Pool Optometrist Clinical Psychologist (can prescribe medications) Dental Hygienist Nurse Anesthetist (or other advanced nurse, specify) Orthotist/Orthotic Fitter Social Worker or Licensed Clinical Social Worker (specify) 01 Specified Medical Professionals 07-07-09 Page 1
Hearing Aid Fitter Nurse, Licensed Practical(L.P.N.) Perfusionist Veterinarian E.M.T. (circle ONE): Basic/Intermediate/Paramedic Nurse Practitioner (R.N.P., F.N.P., C.R.N.P.) Pharmacist Visiting Nurse Nursing Registry Association/ Home Health Care Agency Respiratory Therapist (R.R.T., C.R.T., C.P.F.T., R.P.F.T.) (specify) Nurse, Registered (R.N.) Physical Therapist X-ray/CT/MRI Technician Occupational Therapist or Speech Therapist (specify) Physician Assistant (P.A.) Other (specify): (b) Based upon applicant specialty(ies) (indicated in 4. (a) on prior page) is applicant authorized to prescribe and/or administer non-otc medications? [go to #5] (i) If yes, is applicant authorized to prescribe and/or administer controlled substances? [go to #5] (ii) If yes, does applicant prescribe controlled substances? No [go to #5] Yes [go to (iii)] (PLEASE EXPLAIN (NATURE OF ANY CONTROLLED SUBSTANCE PRESCRIPTIONS) (iii) If yes, provide applicant s DEA number: 5. Indicate professional societies or associations in which applicant is a member: 6. Is applicant associated with or does applicant work for a physician or surgeon? If yes, give name and specialty of physician: 7. Indicate percent of time spent in the following work locations: Administrative Office Laboratory Professional Office (specify profession) Classroom Nursing Home Emergency Dept of Hosp. Operating Room Hospital Ward (specify) Outpatient Clinic Other (specify) Patient s Home 8. State approximate division of applicant s patients or clients among: a. Hemodialysis g. Psychiatric m. Bariatrics b. Holistic Medicine h. Drug Addicts n. Physical Rehabilitation c. Surgical i. Alcoholics o. Disability Evaluation d. Stress Testing j. Obstetrical p. Research or Experimental e. Communicable k. Dental q. f. Family Planning l. Pediatric r. 100 9. List the number and type of applicant s employees and volunteers. IF NONE, STATE NONE. # Type of Profession # Type of Profession # Type of Profession # Type of Profession a. Inhalation Therapists e. Nurse Practitioner i. Perfusionists m. Speech Therapists b. Laboratory Technicians f. Nurse, Registered j. Pharmacists n. c. Nurse Anesthetists g. Opticians k. Physiotherapists o. d. Nurses, Licensed Practical h. Optometrists l. Social Workers p. 10. Are all the above individuals licensed in accordance with applicable state and federal regulations? If no, please attach explanation. 01 Specified Medical Professionals 07-07-09 Page 2
11. ATTACH DETAILED EXPLANATION FOR ANY YES ANSWERS. Has the applicant or have any of the above employees: Yes No Ever been the subject of disciplinary or investigative proceedings or reprimand by a governmental or administrative agency, hospital, or professional association? Ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses? Ever been treated for alcoholism or drug addiction? Ever had any state professional license or license to prescribe or dispense narcotics refused, suspended, revoked, renewal refused or accepted only on special terms, or ever voluntarily surrendered same? Ever had any insurance company cancel, decline, refuse to renew, or accept only on special terms, their malpractice insurance? 12. List the number and type of independent contractors who provide professional services on behalf of the applicant. IF NONE, STATE NONE. # Type of Profession # Type of Profession # Type of Profession # Type of Profession a. Inhalation Therapists e. Nurse Practitioner i. Perfusionists m. Speech Therapists b. Laboratory Technicians f. Nurse, Registered j. Pharmacists n. c. Nurse Anesthetists g. Opticians k. Physiotherapists o. d. Nurses, Licensed Practical h. Optometrists l. Social Workers p. 13. Does the applicant supervise any individuals other than its own employees If yes, provide detailed explanation of responsibilities and relationships to the entity which employs these individuals. Also, indicate by profession the number of individuals supervised. # Type of Profession # Type of Profession Physicians X-ray Technicians Laboratory Technicians 14. State sources and amounts of total revenue: Source Amount this Fiscal Year Amount Next Fiscal Year Charitable Contributions $ $ Government Funding $ $ Fee for Service $ $ $ $ TOTAL GROSS REVENUE $ $ 15. Provide number of patient or client encounters: Type of Visit Number of Visits Last 12 Months Number of Visits Next 12 Months Clinic Laboratory TOTAL NUMBER OF VISITS 01 Specified Medical Professionals 07-07-09 Page 3
16. Does the applicant render professional services directly to patients? If yes, please describe in detail these services and indicate extent of supervision by others. Detailed Description of Professional Services Percent of Time Supervised Qualifications of Supervisor 17. Does the applicant render professional services that do not involve contact with a patient? If yes, please describe in detail these services: 18. (a) Do you perform or assist in any surgical procedure(s)? (b) List ALL surgical procedures performed (including minor surgery): (c) Is anesthesia (other than topical or by means of local infiltration) administered by either yourself or others? If yes, attach a detailed explanation. (d) Do you perform or assist in any surgical procedure(s) in a professional office or similar non-hospital facility? If yes, attach a detailed explanation. 19. Does the applicant perform radiation therapy? 20. Does the applicant perform psychiatric shock therapy? 21. Does the applicant prescribe or dispense any drugs without the countersignature of a physician? If yes, attach a detailed explanation. 22. Does applicant compound in bulk, manufacture or wholesale medicine? If yes, provide a detailed explanation. 23. (a) If applicant performs veterinary services, indicate the approximate division of your work among the following categories: Greyhounds Animals valued over $5000 Attach explanation including frequency Thoroughbreds and type of animal treated. (b) Do you administer artificial insemination? If yes, also answer the following questions: (i) What types of animals are involved? (ii) Are you responsible for storage of the semen? Explain: (iii) What percent of your practice is involved with artificial insemination? (c) Are you ever responsible for identifying contagious diseases in your locality and/or for recommending remedial action? If yes, attach explanation. 24. Does applicant own or operate any business other than that shown in Question 1 (a) above? If yes, please give details on a separate sheet. 25. Is the applicant employed by any individual or entity other than that shown in Question 1 (a) above? If yes, please attach explanation, including details of your responsibilities. 01 Specified Medical Professionals 07-07-09 Page 4
26. Is the applicant under contract to any individual or entity other than that shown in Question 1 (a) above? If yes, attach explanation, including details of your responsibilities. If this contract contains a hold-harmless agreement, copy of contract must be attached. 27. Is the applicant in the employ of any governmental entity? If yes, attach explanation, including details of your responsibilities. 28. Is the applicant under contract to any governmental entity? If yes, attach explanation, including details of your responsibilities. 29. Does the applicant advertise its professional services in any manner (other than a simple listing in a telephone directory)? If yes, attach a copy of ALL of its advertise-ments. 30. Is the applicant associated with any agency or organization that engages in any kind of advertising for, or solicitation of, patients? If yes, attach a detailed explanation and a copy of ALL of the advertisements. 31. Does the applicant own (wholly or in part), operate or administer any hospital, nursing home or other institution where medical services are customarily rendered? If yes, give details, including name, location, size and number of beds. 32. If the applicant has a training school, complete the following: (attach a separate schedule if needed) Specify Profession for which Students are # of Sessions being Trained per Year Max # of Students per Session of Time involved in Clinical Setting Qualifications of Faculty (eg. M.D., R.N., Ph.D., D.O., etc.) 33. (a) Does the applicant use a collection agency? If yes, give name of agency: (b) Has the agency authority to file a collection suit at its discretion? 34. Has any claim or suit been brought against the applicant and/or any of its employees? If yes, a supplemental claim information form must be completed for each claim or suit. 35. Are you aware of any circumstances which may result in a malpractice claim or suit being made or brought against the applicant or any of its employees? If yes, give details on a separate sheet. 36. List prior professional liability insurance carried for each of the past four years. IF NONE, STATE NONE. Insurance Carrier Policy # Limits of Liability Deductible (if any) Premium Inception MM/DD/YY Expiration MM/DD/YY Was this a Claims Made Policy Form? Yes No 37. If prior professional liability insurance was on a claims made basis, advise the retroactive exclusion date of the prior coverage: 01 Specified Medical Professionals 07-07-09 Page 5
PART II INDIVIDUAL APPLICANTS ONLY, PLEASE ALSO ANSWER THE FOLLOWING QUESTIONS. 1. Are you a U.S. citizen? If no, please indicate your status and date of entry into the U.S.A. 2. Describe your professional training: Institution (name & address) From Years of Training To Degree or Certification Attained 3. Where have you practiced your profession during the last ten years? In during the years In during the years 4. Have you ever failed any professional licensing or specialty organization examination? If yes, attach a detailed explanation including dates and location. WARRANTY: It is warranted to CampMed Casualty & Indemnity Company of Maryland, Inc. that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Company evidence its acceptance of this application by issuance of a policy. I/We hereby authorize the release of claim information from any prior insurer to CampMed Casualty & Indemnity Company of Maryland, Inc., Underwriting Manager for the Company. PLEASE REVIEW THE POLICY CAREFULLY. Except to such extent as may be provided otherwise in the policy, the policy for which application is being made is limited to ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED while the policy is in force. Signature of Applicant*: Title: Date: * SIGNING THIS FORM DOES NOT BIND THE APPLICANT, THE COMPANY, OR THE UNDERWRITING MANAGER TO COMPLETE THE INSURANCE. Application MUST be currently signed and dated to be considered for quotation. ** REQUIRED ATTACHMENT: COPY(IES) OF ALL CURRENT AND VALID STATE LICENSE(S)/ CERTIFICATION(S) FOR WHICH APPLICANT IS USING AS BASIS FOR APPLICATION FOR THIS INSURANCE POLICY. NO POLICY WILL BE ISSUED WITHOUT A CURRENT AND VALID STATE LICENSE/CERTIFICATION ON FILE WITH THE COMPANY. ** RETURN COMPLETED APPLICATION (INCLUDING ALL REQUIRED ATTACHMENTS AND SUPPLEMENTAL PAGES) TO: CampMed Casualty & Indemnity Company of Maryland, Inc. Attn: Underwriting Department New Business 111 Berry Street, S.E. Vienna, VA 22180 fax: (703) 242-3815 [please limit fax submissions to a maximum of twenty five (25) pages] 01 Specified Medical Professionals 07-07-09 Page 6
FRAUD STATEMENT IL N 001 09 03 Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. DISTRICT OF COLUMBIA FRAUD STATEMENT IL N 026 09 03 WARNING: It is a crime to provide false, or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. PENNSYLVANIA FRAUD STATEMENT IL N 088 09 03 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. VIRGINIA FRAUD STATEMENT IL N 106 09 03 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. 01 Specified Medical Professionals 07-07-09 Page 7