Executive Risk Indemnity Inc. Home Office Wilmington, Delaware 19805-1297 Administrative Offices/Mailing Address: 82 Hopmeadow Street Simsbury, Connecticut 06070-7683 APPLICATION FOR MANAGED CARE SPECIFIC EXCESS INSURANCE Section I General Information 1. Name of Applicant: (Whenever used in this Application, the term Applicant shall mean the Parent Corporation and all subsidiaries.) 2. Principal address: City: State: ZIP: 3. Nature of Applicant s primary business: Hospital PHO IPA Medical Group PPO HMO : _ 4. Primary contact (name and title): Telephone number: Fax number: 5. Name of any subsidiary(ies) or affiliate(s) to be included in this coverage: Address: City: State: ZIP: (Please use additional sheet, if necessary.) 6. Nature of subsidiary s or affiliate s business: Hospital PHO IPA Medical Group PPO HMO : _ Section II Coverages Requested 1. Proposed effective date: _ Hospital Professional Specific Retention(s) Per Covered Person*: $ $ Maximum Benefit For Each Covered Person: $ $ Coinsurance: % % *Retention(s) will be eroded on the same basis as reimbursement for Eligible Costs. 2. Indicate the basis for reimbursement: Eligible Professional Fee Schedule (Type & Conversion Factor) % of Reasonable & Customary (Please Specify) Participating Providers: Non-participating Providers: Form C23993 (3/1997 ed.) 1 Catalog No. PEa-I
Eligible Hospital Per Diem % of Billed (Please Specify) Participating Provider: % Non-participating Provider: % Per Diem Limits (if applicable) Medical/Surgical: ICU: CCU: SICU: NICU: : $ _ $ _ $ _ $ _ $ _ $ _ $ % _% _% _% _% _% _% 3. Check if coverage is requested for transplants of: Bone Marrow Heart Heart/Lung Kidney Liver Pancreas (specify): 4. Referrals: a) Is your organization financially responsible for referrals to other hospitals or providers? Yes No b) What services/treatments are typically referred to other hospitals or providers? c) How do you typically compensate other hospitals or providers for referral services? Section III Enrollment Information 1. Identify the geographic area served by the organization s hospital and medical services: 2. Enrollment for whom coverage is requested: Population Past 12 Months Current Next 12 Months Commercial: Medicare: Medicaid: (specify): 3. Inpatient hospital days per thousand: Population Past 12 Months Current Next 12 Months Commercial: Medicare: Medicaid: (specify): Section IV Stop Loss Coverage Currently In Effect 1. Please provide the following data or attach a copy of your current policy(ies): a) Name of current carrier: Expiration date of current contract: Form C23993 (3/1997 ed.) 2 Catalog No. PEa-I
b) Current coverages: Hospital Professional Retention(s) Per Covered Person: $ $ Limit(s) Per Covered Person: $ $ Coinsurance: % % Commercial Premium PMPM: $ $ Medicare Premium PMPM: $ $ Medicaid Premium PMPM: $ $ 2. Indicate the basis for reimbursement (if different from that requested in Section II): Eligible Professional Fee Schedule (Type & Conversion Factor) % of Reasonable & Customary Participating Provider: % Non-participating % Provider: (Please Specify) Eligible Hospital Per Diem % of Billed (Please Specify) Participating Provider: % Non-participating Provider: % Per Diem Limits (if applicable) Medical/Surgical: ICU: CCU: SICU: NICU: : $ $ $ $ $ $ $ 3. Previous carrier(s) over last thirty-six (36) months (if different from above): 4. Describe previous coverage (if different from above): Section V Experience 1. Provide a brief description of how your organization: a) Secures enrollment from the payor(s): b) Monitors enrollment by the payor(s): c) Controls over-utilization of services: d) Prevents excess length of hospital inpatient stays: e) Assures quality medical service to Covered Persons: f) Provides meaningful peer review: g) wise controls unit costs: Form C23993 (3/1997 ed.) 3 Catalog No. PEa-I
2. Please complete Attachment A to provide information regarding expenses incurred over the last thirty-six (36) months for: a) Hospital Inpatient resulting in charges in excess of $25,000; or b) Professional resulting in charges in excess of $7,500. Section VI Current Claims Please complete Attachment B for any current or proposed Covered Person who: 1. Is hospital-confined as of the date of this Application; 2. Is likely to be hospital-confined as of the effective date of the requested coverage; 3. Is undergoing treatment which may, in your opinion, exceed $25,000 in hospital inpatient services or $7,500 in professional services within the next twelve (12) months; or 4. Is likely to require major surgery, require hospitalization or incur significant other medical expenses within the next twelve (12) months. Section VII Health Care Service Agreement Data Please attach the financial material or complete a separate Attachment C for each Payor whose Health Care Service Agreement is the basis for the requested coverage. Section VIII Signatures FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED AUTHORIZED AGENT OF THE PERSON(S) AND ENTITY(IES) PROPOSED FOR THIS INSURANCE DECLARES THAT TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AFTER REASONABLE INQUIRY, THE STATEMENTS HEREIN ARE TRUE AND COMPLETE. THE UNDERWRITER IS AUTHORIZED TO MAKE INQUIRY IN CONNECTION WITH THIS APPLICATION. SIGNING THIS APPLICATION DOES NOT BIND THE UNDERWRITER TO COMPLETE, OR THE APPLICANT TO PURCHASE, THE INSURANCE. THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE UNDERWRITER AND ALONG WITH THE APPLICATION IS CONSIDERED PHYSICALLY ATTACHED TO THE POLICY AND WILL BECOME PART OF IT. THE UNDERWRITER WILL HAVE RELIED UPON THIS APPLICATION AND ATTACHMENTS IN ISSUING ANY POLICY. THE APPLICATION WILL BECOME A PART OF SUCH POLICY IF ISSUED. IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE EFFECTIVE DATE OF THE POLICY, THE APPLICANT WILL NOTIFY THE UNDERWRITER, WHO MAY MODIFY OR WITHDRAW ANY OUTSTANDING QUOTATION. NOTICE TO ARKANSAS, MINNESOTA AND OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD, WHICH IS A CRIME. NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICY HOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY HOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. NOTICE OF DISTRICT OF COLUMBIA, MAINE AND VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS. NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY EMPLOYER OR EMPLOYEE, INSURANCE COMPANY, OR SELF-INSURED PROGRAM, FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. Form C23993 (3/1997 ed.) 4 Catalog No. PEa-I
NOTICE TO KENTUCKY APPLICANTS: 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 CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. NOTICE TO LOUISIANA AND NEW MEXICO APPLICANTS: 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 CIVIL FINES AND CRIMINAL PENALTIES. NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW YORK APPLICANTS: 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. NOTICE TO OKLAHOMA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY. NOTICE TO OREGON AND TEXAS APPLICANTS: ANY PERSON WHO MAKES AN INTENTIONAL MISSTATEMENT THAT IS MATERIAL TO THE RISK MAY BE FOUND GUILTY OF INSURANCE FRAUD BY A COURT OF LAW. NOTICE TO PENNSYLVANIA APPLICANTS: 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. APPLICANT BY (President and/or CEO Signature) TITLE DATE NOTE: This Application must be signed by the president and/or CEO of the Applicant acting as the authorized agent of the person(s) and entity(ies) proposed for this insurance. PRODUCED BY (Insurance Agent) INSURANCE AGENCY TAXPAYER ID OR SOCIAL SECURITY NO. ADDRESS (No., Street, City, State, and ZIP Code) INSURANCE AGENCY AGENT LICENSE NO. EMAIL ADDRESS SUBMITTED BY (Insurance Agency) INSURANCE AGENCY TAXPAYER ID OR SOCIAL SECURITY NO. AGENT LICENSE NO. ADDRESS (No., Street, City, State, and ZIP Code) Form C23993 (3/1997 ed.) 5 Catalog No. PEa-I
Attachment A Experience Please complete this schedule for all Covered Person(s) who have incurred: a) Hospital inpatient charges in excess of $25,000 over the last thirty-six (36) months; or b) Charges for professional services in excess of $7,500 over the last thirty-six (36) months. Name of Covered Person Diagnosis Date(s) of Hospitalization Hospital Billed Charges Professional (Specify) Hospital Actual Amounts Paid Professional (Specify) Current Status Form C23993 (3/1997 ed.) 6 Catalog No. PEa-I
Attachment B Current Claims Please complete the schedule for any current or proposed Covered Person(s) who: a) Is hospital-confined as of the date of this application; b) Is likely to be hospital-confined as of the effective date of the requested coverage; c) Is undergoing treatment which may, in your opinion, exceed $25,000 in hospital inpatient services or $7,500 in professional charges within the next twelve (12) months; or d) Is likely to require major surgery, require hospitalization or incur significant other medical expenses within the next twelve (12) months. Name of Covered Person Diagnosis Prognosis Hospital Billed Charges Incurred to Date Actual Amounts Paid to Date Estimated Expenses Over the Next 12 Months Professional Hospital Professional Hospital Professional (Specify) (Specify) (Specify) Form C23993 (3/1997 ed.) 7 Catalog No. PEa-I
Attachment C Health Care Service Agreement (HCSA) Data 1. Name of payor:_ 2. Type of payor: 3. Effective date of the HCSA: 4. If payor is or is part of an HMO, is the HMO federally qualified? Yes No 5. Does the HCSA require the Applicant to provide for services under: Medicare: Yes No Medicaid: Yes No 6. Please check the hospital and professional services for which your organization is financially responsible under the HCSA. Hospital Professional Hospital Professional Acute/Intensive care Orthopedics Cardiac Otolaryngolgy/ENT Cardiovascular Pediatrics Medical/Surgical Pharmacy Neo/Natal Pulmonary Allergy/Immunology Radiology: Anesthesiology Diagnostic Burn treatment Therapeutic Cardiology Rehabilitation Dermatology Respiratory Care Dialysis Rheumatology Endocrinology Surgery: Emergency services Cardiovascular Gastroenterology General Gynecology Neurosurgery Infectious diseases Orthopedic Internal medicine Transplants: Labor & delivery Bone marrow Neo/Natal Heart Nephrology Heart and Lung Neurology Kidney Nuclear medicine Liver Obstetrical Pancreas Oncology Trauma Urology 7. Are you unable to provide any services for which you are responsible under this HCSA? Yes No If Yes, please describe: Form C23993 (3/1997 ed.) 8 Catalog No. PEa-I