Individual Provider Application

Please complete the application and remit with dated signature. If additional pages are needed to complete the application, please attach.

"*" indicates required fields

Step 1 of 15

I. Application Information

Name Insured*

Practice Name/Corporation*

Business Address*

Phone Number*

Employee or Independent Contractor*

Employee

Independent Contractor

Email*

Date of Birth*

MM slash DD slash YYYY

Social Security Number*

Requested Effective Date*

MM slash DD slash YYYY

Retroactive Date*

MM slash DD slash YYYY

Specialty*

Hours Worked Per Week (per specialty)*

II. Licensing Information

Identify states in which you are licensed and the percentage of your practice that occurs in each state.

Licensing*

State

License #

Date Licensed

Percent of Practice

III. Insurance History

Provide details of coverage for the past five (5) years, including moonlighting positions during residency but excluding your residency program.

Insurance History*

Carrier

Policy Limits Per Incident

Policy Limits Per Aggregate

Effective Dates

Claims Made or Occurrence

IV. Education History

If one or more of the below do not apply to you, please put N/A in the provided box

Education - Medical School*

Medical School(s) Attended

Location

Dates Attended

Completed (Y/N)

Education - Internship*

Internship(s) Attended

Location

Dates Attended

Completed (Y/N)

Education - Residency*

Residency(ies) Attended

Location

Dates Attended

Completed (Y/N)

Education - Fellowship*

Fellowship(s)

Location

Dates Attended

Completed (Y/N)

V. Board Status Information

Board Status*

Specialty Board(s)

Board Eligibility Date

Date Certified

Current Recertification

VI. Work History

List all the locations and dates where you have practiced medicine since graduation from medical school, including moonlighting positions.

Work History*

City and State

Dates Employed (Month/Year)

VII. Privileges

List all hospitals where you currently have privileges or where privileges are pending:

Privileges*

Hospital

City and State

Active, Courtesy, or Pending

VIII. Surgical Specialty Information

N/A

Not Applicable

MEDICAL Non-Surgical Specialty

Subspecialty(ies)

SURGICAL Specialty

Subspecialty(ies)

If General Surgeon, list subspecialties and % of each performed.

Thoracic, Vascular, Cardiovascular, Trauma

Thoracic

Vascular

Cardiovascular

Trauma

Other (Please Explain)

Do you have a surgical suite in your free-standing office?

Yes

If yes, we will contact you for further information.

Other than local or topical anesthesia, do you administer any anesthetics or moderate sedation outside of a hospital or surgi-center?

Yes

If yes, please complete the following.

Procedure

Anesthesia or Moderate Sedation?

What type of emergency equipment and/or emergency procedures are in place in the case of complications?

IX. OB/GYN Specialty Information

Not Applicable

Number of Caesarian Sections per year

Number of deliveries per year

Do you perform Non-Therapeutic Abortions?

Yes

If yes, number per year

Number performed in your office or a clinic

Do you employ, or have under contract, nurse mid-wives?

Yes

X. Anesthesiology Information

Not Applicable

Are CRNA’s (employed or contracted) always supervised by you or a member of your group?

Yes

What is the average CRNA/MD supervision ratio?

Do you perform anesthesia services outside a hospital or surgi-center?

Yes

XI. Invasive Medical Procedures

Please indicate which invasive or medical procedures listed below in which you partake.

Not Applicable

Amniocentesis

Angiography – CARDIAC

Office or Hospital

Office

Hospital

Angiography – PERIPHERAL

Office or Hospital

Office

Hospital

Angioplasty – CARDIAC

Office or Hospital

Office

Hospital

Angioplasty – PERIPHERAL

Office or Hospital

Office

Hospital

Blepharoplasty

Office or Hospital

Office

Hospital

Breast Surgery

Office or Hospital

Office

Hospital

Bronchoscopy

Office or Hospital

Office

Hospital

Circumcisions – other than newborns

Cosmetic Injectables

Office or Hospital

Office

Hospital

Cryosurgery – other than use on benign, malignant, or pre-malignant dermatological lesions

Dermabrasion or Hair Transplants

Indicate percentage of time devoted:

Indicate percentage of time devoted

D&C’s

Office or Hospital

Office

Hospital

ERCP (Endoscopic Retrograde Cholangiopancreatography)

GI Endoscopy with anesthesia or moderate sedation

Office or Hospital

Office

Hospital

Hemodialysis

Laparoscopic Procedure(s) – DIAGNOSTIC (Attach summary of training)

Laparoscopic Procedure(s) – DIAGNOSTIC

Attach Summary of Training

Drop files here or

Accepted file types: jpg, pdf, doc, docx, Max. file size: 80 MB.

Laparoscopic Procedure(s) – THERAPEUTIC

Attach Summary of Training

Drop files here or

Accepted file types: jpg, pdf, doc, docx, Max. file size: 80 MB.

Specify type*

Specify type

Laser Therapy

Office or Hospital

Office

Hospital

Liposuction

Lithotripsy

Office or Hospital

Office

Hospital

Lymphangiography

Myelography

Needle Biopsy – including lung, prostate, liver and kidney

Placement of access lines for dialysis, chemotherapy, CVP

Pneumoencephalography

Radiation Therapy

Shock Therapy (ECT)

Office or Hospital

Office

Hospital

Swan-Ganz Catheterizations

Annual Number Performed

Annual # performed

Temporary Pacemaker Insertions

Number

Annual # performed

Tubal Ligations

Office or Hospital

Office

Hospital

TURPS (Transurethral Resection of Prostate)

Weight Loss Surgical Procedures

Number

Annual # performed

Specify type*

Specify type

XII. Additional Professional Information

If yes, please provide details on a supplemental form or your own letterhead.

A. Has any licensing authority or hospital ever reprimanded you or ever denied, revoked, suspended, or restricted your medical license, narcotics license or practice privileges or put you on probation?

Yes

B. Has any licensing authority or hospital conducted (or are they currently conducting) an investigation relating to the restriction or limitation of your license or privileges of which you are aware?

Yes

C. Have you ever been diagnosed with, evaluated for, and/or treated for any alcohol, narcotic, or other substance abuse illness, mental health conditions (including without limitations anger management)?

Yes

If yes, please provide details of rehabilitation program/treatment, including dates of treatment.

D. Have you suffered from or been treated for any chronic illness or physical defect?

Yes

If yes, please provide details of treatment, including dates of treatment.

E. Have you ever been without coverage since beginning practice?

Yes

F. Has any similar insurance ever been declined, cancelled, non-renewed, or subjected to special conditions or limitations?

Yes

G. Do you average fewer than 50 hours of Category I CME units annually in your specialty(ies)?

Yes

H. Have there been any changes in your practice or specialty in the past five years?

Yes

I. Are you engaged in any "moonlighting" activity or other health care related activity apart from your practice (including any Emergency Room coverage)?

Yes

If yes, which insurance company covers for this exposure?

J. Are you serving as a Medical Director for any facility?

Yes

If yes, which insurance company provides coverage for this exposure?

K. Do you participate in experimental drug therapy or surgical procedures?

Yes

L. Do you or any of your employees make home health care visits?

Yes

M. If you are not Board Certified, please provide explanation:

If you answered yes to any of the above, please provide documentation.

Drop files here or

Accepted file types: jpg, pdf, doc, docx, Max. file size: 80 MB.

XIII. Claim Information

If yes, please provide details on the SUPPLEMENTAL CLAIM INFORMATION on the next page for each such claim, potential claim or suit, or incident having potential for claim.

A. Have you ever been involved, directly or indirectly, or do you have knowledge of any claim, potential claim, suit, or occurrence having potential for a claim, arising out of the rendering or failing to render professional services?

Yes

If yes, how many?

B. Have you ever been involved, directly or indirectly, or do you have knowledge of any claims or potential claims arising out of the rendering or failing to render professional services involving former or present partners, members of the corporation, or any former or present employee of the corporation, partnership or Professional Association?

Yes

If yes, how many?

C. Have all such claims or occurrences been reported to your present carrier?

Yes

XIV. Supplemental Claim Information

PLEASE COMPLETE ONE FORM FOR EACH CLAIM. If space is insufficient to answer any question fully, please use reverse side or attach a separate sheet. Please do not leave any blanks.

Name of applicant

Name of patient involved with the claim

Date of incident from which claim resulted or which is likely to result in a claim

MM slash DD slash YYYY

Date in which claim was made

MM slash DD slash YYYY

Allegations made against you

Explain in detail the specifics of the incident which led or may lead to the claim

Present status of claim

Active

Dismissed

Dropped

Closed

If closed, please provide the amount of settlement or judgement

Closed with no payment?

Yes

Name of insurance company involved

Name(s) of other doctors and hospitals, if an, involved in the claim or suit

Please attach any additional supplemental claim information

Max. file size: 80 MB.

Signature of Applicant

I understand information submitted herein becomes a part of my Professional Liability Application and is subject to the same representations and conditions.

Date

MM slash DD slash YYYY

XV. Declaration

I understand the submission of this application does not bind the Company to issue or me to purchase this insurance. By signing below, I grant permission (1) to the Company to contact third parties and (2) to third parties to release to the Company information which relates to the issuance and continuation of this insurance. I represent that the information provided in this application (and attachments) and any previous applications is true. I understand (1) that the applications are the basis of and will become a part of the insurance contract with the Company; (2) that the application information I provided is material to the Company; (3) that the Company is relying on this information in determining whether to issue an insurance contract and in establishing the premium to charge for the insurance contract; and (4) that the Company may rescind the insurance contract if any application contains any misrepresentation or omission with intent to deceive. Further, I agree to notify the Company of any change in the information provided.

Signature of Applicant

Date

MM slash DD slash YYYY

Name

This field is for validation purposes and should be left unchanged.