3330 Cobb Parkway, Suite 17-L Acworth, Georgia 30101
PLEASE TYPE OR PRINT YOUR ANSWERS. BE SURE ALL QUESTIONS ARE ANSWERED. 1. _________________________________ 2. _______________________Fax______________________ Name of prospective Partner and/or Clinic
3. _______________________ ____________ ______________________ ____________ _____________ Office Street Address
4. Specialty: _________________________________ Subspecialties (if any): _________________________ 5. _________________________ 6. ________________________ 7. _____________________________ Effective Date Requested
8. _____________________________________________ 9. _______________________________________ D.E.A. #
10. ______________________________________________________ 11. ____________________________ Previous Carrier
12. Limits of Liability requested: _______ $100,000/$300,000 _______ $250,000/$750,000
Do you desire a deductible? ____Y or N____
If yes, amount $ _________________________________
13. Do you practice: _______ Full Time _______ Part Time Number of hours per week __________________ 14. Type of practice: _______ Individual _______ Member of Professional Corporation _______ Partnership _____ Professional Association Other ___________________________________________ 15. If employed (Name of employer): ______________________________________________________________ 16. Please indicate the medical professional organizations of which you are a member: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Continue on a separate page, if necessary. 17. Have you participated in any continuing education programs in the last five years? YES ______ NO ________ If yes, supply details: _____________________________________________________________________________________________ _____________________________________________________________________________________________
17. (Continued) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Continue on a separate page, if necessary.
UNDERWRITING INFORMATION 1. List all colleges and professional schools attended:
_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 2. Postgraduate education: (a) Internship: YES _____ NO _____ Hospital: ____________________________________________________ Address (Country): _________________________________Period of Training (Dates): _________________ Director: ___________________________________ Phone Number: ______________________________ (b) Residency/Fellowship/Preceptorship: YES _____ NO _____ Hospital: _____________________________ Address (Country): _________________________________Period of Training (Dates): _______________ Director: ___________________________________ Phone Number: ______________________________ 3. Board certification: YES _____ NO _____ if yes, name of board and year certified: _____________________ 4. Current Licenses: STATE
Continue on a separate page, if necessary.
5. Have you ever had a license revoked or suspended, or have you been put on probation? YES _____ NO _____ If yes, please explain: _______________________________________________________________________ 6. Have you ever had a narcotic license revoked or suspended, or have you been on probation? YES ____NO____ If yes, please explain: _______________________________________________________________________ 7. Have you ever had your privileges denied, suspended, restricted, revoked or not renewed? YES ___ NO ____ If yes, please explain: _______________________________________________________________________ 8. List all facilities where you do surgery or consultations: NAME
_____________________________________________________________________________________________ 9. Please attach delineation of privileges at each facility. Do you ever perform surgery that is not in your delineation? YES _____ NO _____ If yes, please explain: ________________________________________________________ ______________________________________________________________________________________________ 10. Have you ever used any intoxicant, or other psychoactive or depressant drug to the extent that it has interfered with your ability to perform professional duties? YES _____ NO _____ 11. Have you ever had any professional liability insurance declined, cancelled or renewal refused, for reasons other than the company's withdrawal from your professional liability market? YES _____ NO _____ 12. Have you ever had professional liability insurance issued on a restrictive basis (i.e. reduced limits, assigned a deductible, restricted coverage, surcharge rates)? YES _____ NO _____ 13. Have you ever been the subject of disciplinary proceedings or been reprimanded by an administrative agency, hospital, or professional association? YES _____ NO _____ 14. Have you ever been convicted for an act committed in violation of any law or ordinance other than a traffic offense? YES _____ NO _____ 15. Have you ever been treated for alcoholism or drug addiction? YES ____ NO ____ If yes, which one? _________ 16. Have you ever been disabled or had an interruption of your practice because of a disability? YES____ NO____ IF THE ANSWER TO ANY OF THE QUESTIONS 10 THROUGH 16 IS "YES", PLEASE PROVIDE ADDITIONAL INFORMATION HERE: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________
Continue on a separate page, if necessary.
17. Do you administer any sedatives, analgesics, or anesthesia (besides Xylocaine) in your office? YES ___ NO ___
If yes, please explain: _____________________________________________________________________
______________________________________________________________________________________________ 18. Do you participate in any of the following? Sports medicine? YES ____ NO ____
Minimal incision surgery? YES ____ NO ____ Emergency room work? YES ____ NO ____
a) Do you use a laser in your treatment of patients? YES ____ NO ____
If yes, with what type treatment? ____________________________________________________________
b) How many times per week do you use the laser? _____________________________________________
c) What type of training did you receive in the use of the laser? (check all that apply)
Seminar _____ Course _____ Preceptorship _____ Hands-on _____ Other ________________
Please specify name of program(s): ____________________________________________________
d) Do you advertise? YES ____ NO ____ (if yes, enclose three of your latest advertisements.)
e) Do you place an ad in the yellow pages? YES ____ NO ____ (if yes, enclose a copy of your ads.)
19. Who obtains your informed consent? __________________________________________________________ _____________________________________________________________________________________________ 20. How many patient contacts do you have per week? ________________________________________________ 21. Have you attended a malpractice loss prevention program this past year? YES ____ NO ____ If yes, where, when and describe: __________________________________________________________________________________ ______________________________________________________________________________________________ 22. Have you ever testified as an expert witness? YES ____ NO ____ if yes, for the PLAINTIFF ___ DEFENSE ___ Please explain: ___________________________________________________________________________________ ________________________________________________________________________________________________ 23. Please provide a list of all claims or incidents reported to your current or previous insurers for the past ten (10) years.
a) Have you ever had a malpractice claim presented against you, which was not filed in a city, state , or federal
YES ____ NO ____ If yes, how many? __________. For each claim, closed or pending, regardless of
whether a settlement was reached, complete the Claims History Sheet attached.
ALSO, PLEASE ATTACH A COPY OF THE FINAL PAPERS ON SETTLEMENTS. b) Have you ever had a malpractice claim or lawsuit filed against you with the medical review panel, medical review board, or any arbitration or review committee; or which was filed in a city, state, or federal court? YES ___ NO ___ If yes, how many? __________. For each claim or lawsuit, closed or pending, regardless of whether a settlement was reached, complete the Claims History Sheet attached.
ALSO, PLEASE ATTACH A COPY OF ALL SETTLEMENT DOCUMENTS OR COURT JUDGEMENTS. c) Have you ever paid any settlements or discharged any bills in lieu of having a claim or lawsuit filed against you in a city, state, or federal court, or filed with a medical review panel, medical review board, or any arbitration or review committee?
YES ____ NO ____ If yes, please explain: __________________________________________________
a) Have you, at any time within the retroactive date period requested, or the last two years, received threats of a
malpractice claim or suit against you, or received contacts or communications in any form or manner concerning the filing of a malpractice claim or suit against you?
YES ____ NO ____ If yes, please explain: ___________________________________________________
b) Are you aware of any facts or circumstances, at any time in the last two years, which you believe may give rise
to a malpractice claim or suit against you? YES ____ NO ____ If yes, please explain: _________________________
If the answer to question 24-a or 24-b is yes, have these events or incidents been brought to the attention of your
present or prior carrier? YES ____ NO ____ If yes, please attach a copy of the written notification. If these events or incidents have not been reported to the present or prior carrier, do so immediately, and attach a copy of the written notification to this application. ENCLOSE COPIES OF FINAL PAPERS ON SETTLEMENTS OR COURT JUDGEMENTS. _________________________________________________________________________________________________
I hereby declare and represent that the above statements and particulars are true and complete. I have not withheld or misstated any information requested by the insurance company. I understand and agree that the information contained in this application is material; that it is being relied upon by the company in considering my application for professional liability insurance; and, that it is the basis of any policy of insurance which may be issued to me. I also understand that this application shall be annexed to, and deemed a part of any policy of liability insurance issued to me by the insurance company. Any person who, knowingly and with the intent to defraud any insurance company or other person, files an application for insurance containing any false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime. IT IS FURTHER UNDERSTOOD AND AGREED TO BY ME THAT THERE SHALL BE NO COVERAGE FOR CLAIMS MADE OR CLAIMS ARISING FROM INCIDENTS OCCURRING DURING THE POLICY PERIOD WHICH IS ISSUED UPON THIS APPLICATION, IF ANY OF THE FOLLOWING CONDITIONS APPLY: (1) The claim arises out of the performance of any procedure or surgery not indicated by me in this application. (2) The claim arises from the rendering of professional services outside the scope of the specialty or sub-specialty stated by me in this application (3) Knowledge of or notification of the claim, or an incident has occurred prior to the date below of this application. (4) The claim arises from professional services rendered outside the classification applied for in this application as defined in the classification and rate sheet. _________________
AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize any person, company, insurer, hospital, or other organization to release any and all information, privileged or not, in their dominion, custody, or control regarding insurance applications by me, professional liability insurance issued to me, claims made or suits brought against me, applications by me for hospital privileges, decisions, and notes of any credentials or disciplinary committees involving me, any employment or personnel records involving me, any records of training or experience involving me, and any health, medical, psychological, or psychiatric records involving me as well as any information obtained by any attorneys who are now representing, or have in the past represented, me. I hereby authorize you to make any copies of this application as you deem necessary and those copies shall be as valid as the originals. _________________
REMINDER: MAKE SURE YOU HAVE ANSWERED EVERY QUESTION. CLAIMS HISTORY SHEET (Fill out a sheet for all claims in last 10 years. Make additional copies of this form as necessary) Claimant: Defendant(s): Date Suit filed: City, County, State and Name of Court in which Suit was filed: Name and address of defense attorney: Settlement amount (if any): $
Date case closed: Current status of claim: Name of involved insurance company: Policy number: Brief description of claim: Brief description of defense: AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize any person, company, insurer, hospital or other organization to release any and all information, privileged, or not, in their dominion, custody, or control, regarding insurance applications by me, professional liability issued to me, claims made or suits brought against me, applications by me for hospital privileges, decisions, and notes of any credentials or disciplinary committees involving me, any employment or personnel records involving me, and any health, medical, psychological, or psychiatric records involving me, as well as information obtained by any attorneys who are now representing, or have in the past represented me. ________________________________ _______________________________________________________ Date
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