CNA HealthPro Medical Practitioners Application

CNA HEALTHPRO
MEDICAL PRACTITIONERS APPLICATION
CLAIMS-MADE COVERAGE
PHYSICIANS’ ALTERNATIVE SOLUTIONS - NONSTANDARD PHYSICIANS RENEWAL APPLICATION

Carefully read this page and the questions posed in this application. In order for you to be considered for coverage, this application must be completed in full and submitted along with required attachments and/or supplementary information requested throughout the application.

In order to expedite the underwriting process, please write legibly and ensure that all questions have been fully answered. Additional information may be required upon review of the application.

If the application does not provide you with sufficient space to properly respond to a question, please write “see attached” and respond via separate attachment. Please be sure to sign and date the attachment.

The following required attachments must be submitted along with the fully completed RENEWAL APPLICATION.

Curriculum Vitae/Resume and letterhead IF CHANGED IN THE PAST 12 MONTHS.

Formal, up-to-date loss runs from a prior insurance company IF ANY OF THE FOLLOWING STATEMENTS APPLY:

• There was an open claim, suit or incident pending with the prior carrier at last year’s anniversary;

• An Extended Reporting Period (ERP) Endorsement was purchased from the insurance carrier within the past 5 years;

• Coverage was written on an occurrence basis by the insurance carrier within the past 5 years.

A CLAIM SUPPLEMENTAL FORM or comprehensive narrative on your letterhead must be completed for each claim resolved/closed or new claim made, incident surfacing and/or suit brought against you IN THE PAST 12 MONTHS THAT HAS NOT ALREADY BEEN REPORTED TO CNA.

Please contact your insurance agent if you have any questions concerning this application or the coverage for which this application applies.

NOTE: This is an application for insurance, not an insurance binder. Your application is subject to underwriting review and approval by the company.

I. PERSONAL/PROFESSIONAL DATA

Name (last, first, middle): Designation: MD DO

Business/Entity Name:

IN THE PAST 12 MONTHS, has there been any change in your practice structure or ownership (solo practitioner, solo incorporated group practice, employee, etc.)? No Yes

Current CNA Policy Number: NSD- Social Security Number:

Primary practice address: City: State: Zip Code: County:

Residence address: City: State: Zip Code: County:

Office telephone: Office fax: Residence telephone:

Do you have any other Practice Locations? No Yes

If “Yes”, please list:

Email:

II. MEDICAL SPECIALTY, TRAINING AND LICENSE HISTORY

Please answer all questions completely. If a question does not apply to you, mark “N/A” or “0.” Do not leave any questions unanswered. If space is inadequate, use the space provided under Section V. Comments or use your letterhead.

Medical specialty: Percentage of practice: %

Sub-specialty: Percentage of practice: %

A. Do you limit your practice to the above Specialty and/or Sub-specialty? No Yes

IF NO, please explain:

B. Have you added or discontinued procedures which are considered to be outside of, or not usual to the above practice specialty, or are experimental in nature within the past year or do you anticipate doing so in the near future? No Yes

IF YES, please list procedures/services and note dates of change(s):

C. Have you changed your medical specialty within the past year or do you anticipate doing so in the near future? No Yes

IF YES, please provide complete details and note dates of change(s):

Number of hours continuing education completed within the past two years: hrs.

Please list your Medical Licenses including all active and inactive and your Narcotics/DEA License:

State: License number: Expiration date: Status:

Narcotics/DEA License: Status:

IN THE PAST 12 MONTHS:

a. Has any State/Medical Board refused you a medical license? No Yes

b. Has any State/Medical Board restricted, suspended or revoked your medical license? No Yes

c. Has any State/Medical Board imposed a fine or any other obligation? No Yes

d. Has any State/Medical Board issued a letter of guidance or public reprimand? No Yes

e. Have you voluntarily surrendered a medical license? No Yes

f. Has any State/Medical Board placed you on probation or restricted your practice? No Yes

g. Is your medical license currently under investigation for any reason in any state? No Yes

h. Has your Narcotics/DEA license been surrendered/refused/suspended/revoked (voluntarily or otherwise)? No Yes

i. Has there been any professional conduct or fee complaint filed against you with any Specialty, National, State or County Medical Society, other Professional Association or any licensing or regulatory authority? No Yes

IF YES to any of the above, describe circumstances, outcome, dates and attach copies of any relevant documents.

4. IN THE PAST 12 MONTHS:

a. Have you become American Board Certified or Eligible? No Yes

b. Has your board certification or membership in any medical association/society been refused, suspended, revoked or voluntarily surrendered? No Yes

III. CURRENT MEDICAL PRACTICE

1. Do you employ, supervise or contract with any other physicians? No Yes

2. Do you employ, supervise or contract with any of the following? No Yes

Status: ‘E’ = Employee; ‘S’ = Supervise only; ‘I/C’ = Independent Contractor

3. Which of the following describes your practice?

No Surgery — perform neither surgery nor obstetrical procedures.

Minor Surgery — applies to all general practitioners or specialists... Please list types of procedures routinely performed:

Major Surgery — includes operations in or upon any body cavity... Please list types of procedures routinely performed and number per year:

4. Provide average number of patients seen per week:

5. Is any percentage of your practice devoted to practicing as a locum tenens? No Yes IF YES, what %

6. Are you professionally associated with and/or do you provide professional services on behalf of and/or do you have a financial interest in any of following? Please answer all that apply.

7. Do you perform the following procedures?

IF YES to any of the above marked with an asterisk (**), please explain fully under Section V. or on your letterhead.

8. Have you become a Medical Director or have you accepted similar type responsibilities...? No Yes

9. Have you provided professional services on behalf of a jail, prison, correctional facility, detention center, halfway house or similar type facility? No Yes

IF YES, provide total number of hours per month:

10. Have you performed/provided consultations, diagnosed and/or treated, provided medical advice and/or opinions, reviewed slides or specimens, prescribed medications, sold products or services via telecommunications, video, electronic information systems or the Internet? No Yes

IF YES, provide details (including list of states in which services were provided):

11. Have you performed any procedures/surgeries considered to be experimental in nature and/or not currently approved by the FDA? No Yes

IF YES, provide details:

12. Have you become involved or associated with any devices (including implants) considered to be experimental and/or not currently approved by the FDA? No Yes

IF YES, provide details:

13. Have you worked in a hospital Emergency Room other than to fulfill requirements for your hospital privileges? No Yes

IV. CLAIMS HISTORY

1. IN THE PAST 12 MONTHS, have there been any claims made, incident surfacing and/or suit brought against you alleging damages resulting from a medical incident? No Yes

IF YES, have all such matters been reported to and acknowledged by CNA? No Yes

IF YES, have all such matters been reported to and acknowledged by any other insurance carrier? No Yes

COMPLETE A CLAIM SUPPLEMENTAL FORM OR A NARRATIVE ON YOUR LETTERHEAD PROVIDING COMPLETE DETAILS.

2. IN THE PAST 12 MONTHS, have any claim(s) reported on last year’s application been adjudicated, settled, closed, dismissed or otherwise changed in status? No Yes

IF YES, please provide details:

V. COMMENTS SECTION

Question number:

AUTHORIZATION

I have answered the questions in the Application to the best of my ability and declare that, to the best of my knowledge, the statements set forth herein are true and correct. My signing of the Application does not bind the Insurance Company to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a policy be issued.

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 or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

Name - Please print

ALL QUESTIONS MUST BE ANSWERED AND THE APPLICATION MUST BE SIGNED AND DATED.

This program is underwritten by and Application is made to one of the CNA Insurance Companies. CNA is a registered service mark of the CNA Financial Corporation.