NURSE PROFESSIONAL LIABILITY

Transcription

1 8722 S. Harrisn St. Sandy, UT P.O. Bx 4439 Sandy, UT Fax NURSE PROFESSIONAL LIABILITY 1. General Infrmatin Prpsed Effective Date: Applicant is (check all that apply): Registered Nurse (RN), First Year Graduate Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Vcatinal Nurse (LVN), Aides Assistants Nurse Practitiner (NP) Clinical Nurse Specialist (CNS) (with prescriptive r medical diagnstic authrity) CNS (withut prescriptive r medical diagnstic authrity) Other: Applicant s Name: Applicant s Mailing Address: City: State: Zip: Cunty: Business Telephne Number: ( ) Fax: ( ) Physical Lcatin f Business (if different): Ppulatin within 50 miles: Other Lcatins Used: Physical Address: City: State: Zip: Physical Address: City: State: Zip: Please list any ther names the business is r has been knwn by: Cntact Persn: Prducer N.: Prducer s Name: Prducer s 2. Business Infrmatin Detailed descriptin f business activities (specifically, and by lcatin): Hw many years have yu been in business? Will yu be practicing as: (please check all that apply) An Individual (Full Name): A Sl Crpratin Name f Crpratin: Any dba s r trade names? If yes, please list: A Shareh9lder f a Medical Crpratin Name f Crpratin and Names f ther Sharehlders: A Partner in a Medical Partnership Name f Partnership and Name(s) f Partner(s): A Prfessinal Assciatin Name f Prfessinal and Names f Assciates: UDA-A DEC2012 Page 1 f 6

2 An Emplyer Name f Emplyer ( Please specify if emplyed by an Individual, Crpratin, Partnership, IPA, HMO): An Independent Cntractr Name f Individual, Crpratin r Partnership with whm yu cntract: Sharing ffice space and/r expenses nly Names f Assciates: Are yu practicing as part f any affiliatin nt nted abve? If yes, please explain: D yu emply, cntract with r supervise any ther healthcare prviders? If yes, please explain: Name f licensed physician with whm yu cllabrate. If nt, please indicate yur referral relatinships. Annual Payrll: $ Des yur cmpany have within its staff f emplyees, a psitin whse jb descriptin deals with prduct liability, lss cntrl, safety inspectins, engineering, cnsulting, r ther prfessinal cnsultatin advisry services? If yes, please tell us: Emplyee Name: Business Telephne N.: ( ) Fax: ( ) Years with Cmpany: Emplyee s Respnsibilities: 3. Insurance Histry Wh is yur current insurance carrier (r yur last if n current prvider)? Prvide name(s) fr all insurance cmpanies that have prvided Applicant insurance fr the last three years: Cmpany Name Expiratin Date Cverage: Cverage: Cverage: Annual Premium $ $ $ Cverage Limits If yu carry malpractice insurance, where des it cver yur wrk? Hme Births Hspital Clinics Has any insurance carrier ever declined, surcharged, rated-up, restricted, cancelled r refused t renew yur medical malpractice insurance? If yes, please explain: UDA-A DEC2012 Page 2 f 6

3 Has the Applicant r any predecessr r related persn r entity ever had a malpractice claim, suit r incident? Attach a five year lss/claims histry, including details. (REQUIRED) Have yu had any incident, event, ccurrence, lss, r Wrngful Act which might give rise t a Claim cvered by this Plicy, prir t the inceptin f this Plicy? If yes, please explain: Has the Applicant, r anyne n the Applicant s behalf, attempted t place this risk in standard markets? If the standard markets are declining placement, please explain why: 4. Desired Insurance Limit f Liability: $100,000 per accident / $300,000 aggregate $200,000 per accident / $300,000 aggregate $250,000 per accident / $500,000 aggregate $250,000 per accident / $1,000,000 aggregate Other: Self-Insured Retentin (SIR): $1,000 (Minimum) $1,500 $2,500 $5,000 $10, Business Activities A. Prfessinal Designatin Adult, Behaviral/Mental Health, Cmmunity Health, Csmetic Prcedures, Critical Care/ICU Critical Care, Emergency Rm, Family Practice, Family Planning, Gerntlgy, Gyneclgy, Hme Health Care, Hspice, Hspital, Lng Term Care, Maternal & Child, Medical Surgical Midwifery, Nenatlgy, Nursing Hme, Obstetrics Labr and Delivery, Onclgy, Pediatric, Primary Care, Psychiatric, Urgent Care, Wmen s Healthcare Other B. Describe in detail the regular peratins and services yu prvide: C. Average/est. # f patient visits per week: D. Average/est. # f hurs wrked per week: State license/certificatin: Primary state: _ Lic.# Dt. Issued: Temp. exp date: Other States Licensed: List states, number and date DEA Number: E. Persn prviding accunting and tax services: a. Name: b. Address: F. Are yu seeking: a. Insurance t cver wrk dne exclusively by yu? UDA-A DEC2012 Page 3 f 6

4 b. Insurance t cver wrk dne by thers under yur directin? c. Insurance t cver the actins f individuals n yur payrll? G. Emplyee breakdwn (if applicable) please enter the number f: Operatinal Staff Nn-Operatinal emplyees (drivers, cllectrs, supervisrs, etc.) Full-Time Part-Time H. List all Hspitals (name and lcatin) where yu have r are applying fr staff privileges. I. Have yu ever applied fr admitting privileges and been turned dwn? J. Please attach a cpy f risk criteria. K. D yu have transfer agreements with any hspitals? If yes, please identify: L. D yu have a physician write rders? M. D yu have prescriptive privileges? N. D yu supervise students? 4. Medical Training/Educatin Please include a current cpy f yur curriculum vitae (CV) and a cpy f yur practitiner/assciate certificate. Attaching a CV des nt preclude the need t fully cmplete this applicatin. Institutin/Prgram: NAME OF INSTITUTION CITY/ STATE COUNTRY Frm: Other: DEGREE /CERTIFICATION MONTH/YR MONTH/YR NAME OF INSTITUTION CITY/ STATE COUNTRY Frm: DEGREE /CERTIFICATION MONTH/YR MONTH/YR 5. Practice Infrmatin A. Where have yu practiced yur prfessin since cmpletin f yur frmal training? (Include military r any public service rganizatin.) Please accunt fr all time since training. Please explain any gaps in yur educatin r prfessin practice histry. Name f Emplyer City State Frm: Mnth/Yr T: Mnth/Yr T: T: 6. Additinal Underwriting Infrmatin If nt applicable, please nte with a N/A. UDA-A DEC2012 Page 4 f 6

5 A. Have yu ever: 1. been cnvicted f a crime ther than a traffic vilatin? 2. suffered frm r been treated fr substance abuse, mental illness r serius health r physical cnditin? 3. had a cmplaint filed against yu with an State Regulatry Bard? 4. had any prfessinal license/permit r narctics license investigated, suspended, revked, restricted r placed n prbatin? 5. been warned abut yur perfrmance r placed n any type f prbatin during yur training? If yu answered yes t any f the abve, please explain: B. Des yur practice cmply in every way with the rules, regulatins, guidelines and standard as set frth by yur State Regulatry Bard? C. D yu elicit recrd and evaluate a health, psychscial and develpmental histry f the patient? D. D yu perfrm a physical examinatin? E. Briefly describe techniques and instrument used: F. D yu rder r perfrm apprpriate diagnstic tests? G. D yu discriminate between nrmal and abnrmal findings n the histry, physical examinatin, diagnstic tests, initiate referral and cnslatin when apprpriate? H. D yu regulate r adjust medicatins and treatment as prescribed r authrized by a licensed physician? I. Describe any ther prcedures, treatments, r duties yu perfrm: J. D yu have any medical-related duties r practice activities that are insured elsewhere r fr which yu d nt desire cverage? if yes, please explain: K. D yu prvide weight lss treatment r diet therapy? L. D yu prvide healthcare services t crrectinal facilities? REPRESENTATIONS AND WARRANTIES The Applicant is the party t be named as the "Insured" in any insuring cntract if issued. By signing this Applicatin, the Applicant fr insurance hereby represents and warrants that the infrmatin prvided in the Applicatin, tgether with all supplemental infrmatin and dcuments prvided in cnjunctin with the Applicatin, is true, crrect, inclusive f all relevant and material infrmatin necessary fr the Insurer t accurately and cmpletely assess the Applicatin, and is nt misleading in any way. The Applicant further represents that the Applicant understands and agrees as fllws: (i) the Insurer can and will rely upn the Applicatin and supplemental infrmatin prvided by the Applicant, and any ther relevant infrmatin, t assess the Applicant s request fr insurance cverage and t qute and ptentially bind, price, and prvide cverage; (ii) the Applicatin and all supplemental infrmatin and dcuments prvided in cnjunctin with the Applicatin are warranties that UDA-A DEC2012 Page 5 f 6

6 will becme a part f any cverage cntract that may be issued; (iii) the submissin f an Applicatin r the payment f any premium des nt bligate the Insurer t qute, bind, r prvide insurance cverage; and (iv) in the event the Applicant has r des prvide any false, misleading, r incmplete infrmatin in cnjunctin with the Applicatin, any cverage prvided will be deemed vid frm initial issuance. The Applicant hereby authrizes the Insurer and its agents t gather any additinal infrmatin the Insurer deems necessary t prcess the Applicatin fr quting, binding, pricing, and prviding insurance cverage including, but nt limited t, gathering infrmatin frm federal, state, and industry regulatry authrities, insurers, creditrs, custmers, financial institutins, and credit rating agencies. The Insurer has n bligatin t gather any infrmatin nr verify any infrmatin received frm the Applicant r any ther persn r entity. The Applicant expressly authrizes the release f infrmatin regarding the Applicant s lsses, financial infrmatin, r any regulatry cmpliance issues t this Insurer in cnjunctin with cnsideratin f the Applicatin. The Applicant further represents that the Applicant understands and agrees the Insurer may: (i) present a qute with a Sublimit f liability fr certain expsures, (ii) qute certain cverages with certain activities, events, services, r waivers excluded frm the qute, and (iii) ffer several ptinal qutes fr cnsideratin by the Applicant fr insurance cverage. In the event cverage is ffered, such cverage will nt becme effective until the Insurer s accunting ffice receives the required premium payment. The Applicant agrees that the Insurer and any party frm whm the Insurer may request infrmatin in cnjunctin with the Applicatin may treat the Applicant s facsimile signature n the Applicatin as an riginal signature fr all purpses. The Applicant acknwledges that under any insuring cntract issued, the fllwing prvisins will apply: 1. A single Accident, r the accumulatin f mre than ne Accident during the Plicy Perid, may cause the per Accident Limit and/r the annual aggregate maximum Limit f Liability t be exhausted, at which time the Insured will have n further benefits under the Plicy. 2. The Insured may request the Insurer t reinstate the riginal Limit f Liability fr the remainder f the Plicy perid fr an additinal cverage charge, as may be calculated and ffered by the Insurer. The Insurer is under n bligatin t accept the Insured's request. 3. The Applicant understands and agrees that the Insurer has n bligatin t ntify the Insured f the pssibility that the maximum Limit f Liability may be exhausted by any Accident r cmbinatin f Accidents that may ccur during the Plicy Perid. The Insured must determine if additinal cverage shuld be purchased. The Insurer is expressly nt bligated t make a determinatin abut additinal cverage, nr advise the Insured cncerning additinal cverage. 4. The Insurer is herein released and relieved frm any and all respnsibility t ntify the Insured f the pssible reductin in any applicable Limit f Liability. The Insured herein assumes the sle and individual respnsibility t evaluate, cnsider, and initiate a request fr additinal cverage r reinstatement f the annual aggregate Limit f Liability which may be exhausted by any single Accident r cmbinatin f Accidents during the Plicy Perid. Dated: Applicant: Dated: Agent/Brker: Signature Signature Print Name Print Name UDA-A DEC2012 Page 6 f 6