Healthcare Medical Liability Application

HEALTHCARE MEDICAL LIABILITY APPLICATION

Complete all sections of this application. If a question does not apply, enter N/A. All statements in this application are representations and warranties upon which consideration of coverage will be based. The applicant authorizes investigation of any statement made herein, and acknowledges that any material misrepresentation, omission, or incorrect statement may be grounds for denial of coverage or rescission of any policy issued.

A. APPLICANT INFORMATION

Individual / Sole Practitioner
Professional Corporation
Partnership
Limited Liability Company (LLC)
Hospital
Clinic / Group Practice
Other

B. CONTACT FOR UNDERWRITING

C. COVERAGE REQUESTED

Requested Effective Date:

Retroactive Date (Prior Acts Coverage):

D. PRACTITIONERS TO BE INSURED

Practitioner 1

Date of Birth:

Within the past ten (10) years has Practitioner 1 been the subject of any malpractice claim, suit, settlement, judgment, disciplinary action, restriction, or investigation? Yes No

Practitioner 2 (if applicable)

Date of Birth:

Within the past ten (10) years has Practitioner 2 been the subject of any malpractice claim, suit, settlement, judgment, disciplinary action, restriction, or investigation? Yes No

E. PRACTICE LOCATIONS

F. PROFESSIONAL OPERATIONS & PROCEDURES

Indicate services provided (check all that apply):
Primary Care
Surgery
Obstetrics / Deliveries
Anesthesia / Sedation
Cosmetic / Aesthetic Procedures
Telemedicine
Behavioral Health
Radiology / Imaging
Emergency Care
Other

G. PRIOR INSURANCE & CLAIMS HISTORY

Has the applicant or any proposed insured had malpractice insurance in the past? Yes No

Has any claim, suit, demand, or incident been made against the applicant or any proposed insured in the last ten (10) years? Yes No

H. RISK MANAGEMENT & CREDENTIALING

Does the applicant maintain written policies and procedures for clinical care, infection control, record retention, and patient consent? Yes No

Does the applicant maintain a formal peer review or quality assurance program? Yes No

I. REPRESENTATIONS, AUTHORIZATION & CERTIFICATION

By signing below, the applicant and any person completing this application represent and warrant that to the best of their knowledge the statements contained in this application are true, complete, and correct. The applicant understands that this application, including any attachments and materials submitted in connection herewith, will be relied upon by the insurer in determining whether to provide insurance and in setting the terms and premium for any policy issued.

The applicant authorizes the release of medical, employment, credentialing, claims and underwriting information to the insurer and its representatives as may be necessary for underwriting, claims handling and audit. This authorization includes patient records and protected health information to the extent reasonably necessary to investigate claims or potential claims and to determine coverage. This authorization does not waive applicable patient privacy protections except as necessary for underwriting and claims handling as described above.

The applicant further acknowledges that any material misrepresentation, concealment or omission in this application or in the materials submitted in connection with this application may give rise to denial of coverage, rescission of any policy issued, or other remedies available under law. The applicant agrees to promptly notify the insurer of any material change in the facts set forth in this application that occurs prior to the effective date of coverage.

Fraud Warning: Any person who knowingly presents a false or fraudulent statement or material in connection with an application for insurance may be subject to criminal and civil penalties under applicable law.

The undersigned certifies that they are an authorized representative of the applicant and have authority to execute this application on behalf of the applicant. The undersigned understands that signing this application does not bind the insurer to provide coverage but that the insurer may use the information provided to evaluate the application.

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