Healthcare Liability Application

HEALTHCARE LIABILITY APPLICATION

Applicant Information

Applicant Name:

Date of Birth:    Social Security/Tax ID (last 4 digits):

Practice / Business Information

Tax ID / EIN:    NPI Number:

Entity Type (select all that apply)

Individual Practitioner    Professional Corporation    Partnership
Clinic / Hospital    Other:

License, Credentials & Qualifications

Primary State License State:    License Number:

License Issue Date:    License Expiration Date:

DEA/Controlled Substances Registration #:

Specialty, Procedures & Practice Scope

Average annual patient encounters:    Average visit length (minutes):

Coverage Requested

Limit of Liability Requested (per occurrence / aggregate):

Policy Type Requested: Occurrence    Claims-Made

Retroactive Date (if Claims-Made):    Requested Effective Date:

Prior Insurance & Claims History

Prior Policy Period From:    To:    Limits:

Have any claims, suits, disciplinary actions, or investigations been made against you in the past 10 years?    Yes    No

Practice Operations, Delegation & Risk Management

Do you supervise physician assistants, nurse practitioners, residents, or other mid-level providers?    Yes    No

Do you utilize an electronic medical record (EMR) system?    Yes    No    If yes, name/briefly describe:

Attachments

Include the following with your submission:
Curriculum Vitae / CV    Loss Runs (past 5 years)    Clinical Protocols / Consent Forms    Other:

Authorization, Representations & Certifications

By signing below, the applicant certifies that the statements and information contained in this application and any attachments are true, complete and accurately represent the applicant's current operations, history and exposures. The applicant acknowledges that material misrepresentation, omission, or concealment of fact may result in denial of coverage, rescission or voiding of the policy, and forfeiture of premiums as permitted by applicable law.

The applicant authorizes any hospital, medical facility, insurer, employer, licensing board, or other entity to furnish to the insurer or its representatives any records or information requested in connection with this application, underwriting, or claim investigation. This authorization is valid for the period indicated below and may be revoked only in writing; however, information obtained prior to revocation may still be used by the insurer.

Applicant expressly acknowledges that issuance of a policy, if any, will be governed solely by the terms, conditions, exclusions and endorsements of the issued policy. No statements made in this application shall modify or amend the policy unless incorporated in writing into the policy by the insurer.

Acknowledgement

Applicant acknowledges that the insurer may rely upon this application and attachments in determining eligibility for coverage. Applicant agrees to promptly notify the insurer in writing of any material changes in operations, credentialing, claims or licensing status that occur prior to policy inception.

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