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 6% CompanyThis field is for validation purposes and should be left unchanged.I. Application InformationName Insured*Practice Name/Corporation*Business Address*Phone Number*Employee or Independent Contractor* Employee Independent Contractor Email* Date of Birth* Social Security Number*Requested Effective Date* Retroactive Date* Specialty*Hours Worked Per Week (per specialty)* II. Licensing InformationIdentify states in which you are licensed and the percentage of your practice that occurs in each state.Licensing*StateLicense #Date LicensedPercent of Practice Add Remove III. Insurance HistoryProvide details of coverage for the past five (5) years, including moonlighting positions during residency but excluding your residency program.Insurance History*CarrierPolicy Limits Per IncidentPolicy Limits Per AggregateEffective DatesClaims Made or Occurrence Add Remove IV. Education HistoryIf one or more of the below do not apply to you, please put N/A in the provided boxEducation - Medical School*Medical School(s) AttendedLocationDates AttendedCompleted (Y/N) Add RemoveEducation - Internship*Internship(s) AttendedLocationDates AttendedCompleted (Y/N) Add RemoveEducation - Residency*Residency(ies) AttendedLocationDates AttendedCompleted (Y/N) Add RemoveEducation - Fellowship*Fellowship(s)LocationDates AttendedCompleted (Y/N) Add Remove V. Board Status InformationBoard Status*Specialty Board(s)Board Eligibility DateDate CertifiedCurrent Recertification Add Remove VI. Work HistoryList all the locations and dates where you have practiced medicine since graduation from medical school, including moonlighting positions.Work History*City and StateDates Employed (Month/Year) Add Remove VII. PrivilegesList all hospitals where you currently have privileges or where privileges are pending:Privileges*HospitalCity and StateActive, Courtesy, or Pending Add Remove VIII. Surgical Specialty InformationN/A Not Applicable MEDICAL Non-Surgical SpecialtySubspecialty(ies)SURGICAL SpecialtySubspecialty(ies)If General Surgeon, list subspecialties and % of each performed.Thoracic, Vascular, Cardiovascular, TraumaThoracicVascularCardiovascularTrauma Add RemoveOther (Please Explain)Do you have a surgical suite in your free-standing office? Yes No 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 No If yes, please complete the following. ProcedureProcedureAnesthesia or Moderate Sedation?What type of emergency equipment and/or emergency procedures are in place in the case of complications? Add Remove IX. OB/GYN Specialty InformationNot Applicable Not Applicable Number of Caesarian Sections per yearNumber of deliveries per yearDo you perform Non-Therapeutic Abortions? Yes No If yes, number per yearNumber performed in your office or a clinicDo you employ, or have under contract, nurse mid-wives? Yes No X. Anesthesiology InformationNot Applicable Not Applicable Are CRNA’s (employed or contracted) always supervised by you or a member of your group? Yes No What is the average CRNA/MD supervision ratio?Do you perform anesthesia services outside a hospital or surgi-center? Yes No XI. Invasive Medical ProceduresPlease indicate which invasive or medical procedures listed below in which you partake. NA Not Applicable Amniocentesis Amniocentesis Angiography – CARDIAC Angiography – CARDIAC Office or Hospital Office Hospital Angiography – PERIPHERAL Angiography – PERIPHERAL Office or Hospital Office Hospital Angioplasty – CARDIAC Angioplasty – CARDIAC Office or Hospital Office Hospital Angioplasty – PERIPHERAL Angioplasty – PERIPHERAL Office or Hospital Office Hospital Blepharoplasty Blepharoplasty Office or Hospital Office Hospital Breast Surgery Breast Surgery Office or Hospital Office Hospital Bronchoscopy Bronchoscopy Office or Hospital Office Hospital Circumcisions – other than newborns Circumcisions – other than newborns Cosmetic Injectables Cosmetic Injectables Office or Hospital Office Hospital Cryosurgery – other than use on benign, malignant, or pre-malignant dermatological lesions Cryosurgery – other than use on benign, malignant, or pre-malignant dermatological lesions Dermabrasion or Hair Transplants Dermabrasion or Hair Transplants Indicate percentage of time devoted:Indicate percentage of time devotedD&C’s D&C’s Office or Hospital Office Hospital ERCP (Endoscopic Retrograde Cholangiopancreatography) ERCP (Endoscopic Retrograde Cholangiopancreatography) GI Endoscopy with anesthesia or moderate sedation GI Endoscopy with anesthesia or moderate sedation Office or Hospital Office Hospital Hemodialysis Hemodialysis Laparoscopic Procedure(s) – DIAGNOSTIC (Attach summary of training) Laparoscopic Procedure(s) – DIAGNOSTIC Attach Summary of Training Drop files here or Select files Accepted file types: jpg, pdf, doc, docx, Max. file size: 50 MB. Laparoscopic Procedure(s) – THERAPEUTIC Laparoscopic Procedure(s) – THERAPEUTIC Attach Summary of Training Drop files here or Select files Accepted file types: jpg, pdf, doc, docx, Max. file size: 50 MB. Specify type*Specify typeLaser Therapy Laser Therapy Office or Hospital Office Hospital Liposuction Liposuction Lithotripsy Lithotripsy Office or Hospital Office Hospital Lymphangiography Lymphangiography Myelography Myelography Needle Biopsy – including lung, prostate, liver and kidney Needle Biopsy – including lung, prostate, liver and kidney Placement of access lines for dialysis, chemotherapy, CVP Placement of access lines for dialysis, chemotherapy, CVP Pneumoencephalography Pneumoencephalography Radiation Therapy Radiation Therapy Shock Therapy (ECT) Shock Therapy (ECT) Office or Hospital Office Hospital Swan-Ganz Catheterizations Swan-Ganz Catheterizations Annual Number PerformedAnnual # performedTemporary Pacemaker Insertions Temporary Pacemaker Insertions NumberAnnual # performedTubal Ligations Tubal Ligations Office or Hospital Office Hospital TURPS (Transurethral Resection of Prostate) TURPS (Transurethral Resection of Prostate) Weight Loss Surgical Procedures Weight Loss Surgical Procedures NumberAnnual # performedSpecify type*Specify type XII. Additional Professional InformationIf 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 No 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 No 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 No 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 No If yes, please provide details of treatment, including dates of treatment.E. Have you ever been without coverage since beginning practice? Yes No F. Has any similar insurance ever been declined, cancelled, non-renewed, or subjected to special conditions or limitations? Yes No G. Do you average fewer than 50 hours of Category I CME units annually in your specialty(ies)? Yes No H. Have there been any changes in your practice or specialty in the past five years? Yes No I. Are you engaged in any "moonlighting" activity or other health care related activity apart from your practice (including any Emergency Room coverage)? Yes No If yes, which insurance company covers for this exposure?J. Are you serving as a Medical Director for any facility? Yes No If yes, which insurance company provides coverage for this exposure?K. Do you participate in experimental drug therapy or surgical procedures? Yes No L. Do you or any of your employees make home health care visits? Yes No 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 Select files Accepted file types: jpg, pdf, doc, docx, Max. file size: 50 MB. XIII. Claim InformationIf 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 No 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 No If yes, how many?C. Have all such claims or occurrences been reported to your present carrier? Yes No XIV. Supplemental Claim InformationPLEASE 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 applicantName of patient involved with the claimDate of incident from which claim resulted or which is likely to result in a claim Date in which claim was made Allegations made against youExplain in detail the specifics of the incident which led or may lead to the claimPresent status of claim Active Dismissed Dropped Closed If closed, please provide the amount of settlement or judgementClosed with no payment? Yes No Name of insurance company involvedName(s) of other doctors and hospitals, if an, involved in the claim or suitPlease attach any additional supplemental claim informationMax. file size: 50 MB. Signature of ApplicantI understand information submitted herein becomes a part of my Professional Liability Application and is subject to the same representations and conditions.Date XV. DeclarationI 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 ApplicantDate
