Policyholder/Entity Name: Licensed State: Organization NPI Number:

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1 1. Entity Information Podiatry Insurance Company of America Insured Organization Application This is an Application for a Claims-Made Policy. PLEASE PRINT CLEARLY AND ANSWER ALL QUESTIONS. Submission of a complete application confers no obligation upon the Company to bind coverage. For assistance with the application call option 3, option 2. Policyholder/Entity Name: Tax ID Number: Licensed State: Organization NPI Number: If applicable, Doing Business As (DBA) Names: (DBA Doing Business As is the name you operate your business under which differs from your legal name.) Website Address: Primary Practice Address: City: State: Zip Code: County: Office Phone: Fax: Primary Contact Name: Title: The primary contact should be the individual authorized to interact directly with us on your insurance coverage. Preferred method of contact: Phone Fax Additional Practice Address: City: State: Zip Code: County: Mailing Address (if different from Primary Practice Address): City: State: Zip Code: 2. Coverage A. Select coverage option desired. Shared Limit OR Separate Limit* * NOTE: Separate Limit Coverage is the ONLY option available for practices in CT, KS, PA and IN (if enrolled in the Indiana PCF Fund). Attach a copy of the entity s Declarations Page or Coverage Summary from current insurance company showing retroactive date. Include a copy of the Articles of Incorporation (PC/PA) or Organization (LLC). B. Is the entity currently insured? Yes Insurance company: Expiration date: / / No Please attach a summary that includes the last date of entity coverage and insurance company. C. Requested Effective Date of Coverage: / / Retroactive Date Requested: / / Please Note: If entity is currently not insured, the requested effective date cannot be backdated and retroactive coverage is not available. D. Limits of Liability: All owners/shareholders of the Insured Organization are required to carry the same limits of liability (except as otherwise required by state law). The Insured Organization is required to also carry this same limit of liability. Podiatry Insurance Company of America Page 1 of 6

2 E. Complete details for all individuals employed by the entity. If any listed below are insured by another carrier, please include copy of Declarations Page or Coverage Summary for other company. Title/Job Description Number of Employees F. Complete details for all Owners/Shareholders. If any listed below are insured by another carrier, please include copy of Declarations Page or Coverage Summary for other company. Underwriting guidelines may differ by state. Name Specialty/Profession Insurance Company Limits of Liability 3. Entity Details A. Has the entity ever been involved in a professional incident? The word incident as used in this question refers to any claim, demand for damages, resolved or pending, regardless of the result, arising from your professional activity and brought against you or any partner, associate, employee or professional corporation or partnership. Yes No If yes, please describe in the Supplementary Claims Information Form at the end of the application. B. Has the entity in the last 12 months been: i. investigated by or entered into any consent agreement with any formal board or other review committee? Yes No ii. named in any action relating to sexual misconduct? Yes No C. Does the entity engage in any business activities other than the practice of podiatric medicine? Yes No If yes, please describe. Podiatry Insurance Company of America Page 2 of 6

3 4. State Fund Coverage This section is only applicable to those corporations licensed in or having practice locations in Indiana, Kansas, Louisiana or Pennsylvania. If you have no activity in any of these states you may skip this section. If you practice in: A. Indiana: Our corporation is currently enrolled in the Indiana Patients Compensation Fund (PCF). PCF retroactive date: / / Our corporation is not currently enrolled.* *If your corporation is not currently enrolled, do you wish to join (the PCF is optional)? Yes Requested effective date: / / PCF retroactive date requested: / / No If your corporation is enrolled in the PCF, the only limits option available is $250K/$750K. The PCF limits will apply excess of your policy with us. IMPORTANT NOTE: If your corporation is enrolled in the PCF, the corporation may not share limits of liability with employees or any medical professionals. B. Kansas: Note: Participation in the Kansas Health Care Stabilization Fund (HCSF) is mandatory for all health care providers based in Kansas as defined at Health Care Provider Insurance Availability Act [K.S.A (f)], and for any licensed Kansas Corporation. Our corporation is enrolled in the Kansas HCSF. HCSF corporate retroactive date: / / Our corporation is not currently enrolled and is not required to be enrolled. If your corporation is enrolled in the HCSF, the only limits option available is $200K/$600K. The HCSF limits of $100K/$300K, $300K/$900K or $800K/$2.4M will apply excess of your policy with us. IMPORTANT NOTE: The corporation may not share limits of liability with employees or any healthcare providers. C. Louisiana: Our corporation is currently enrolled in the Louisiana Patients Compensation Fund (PCF). PCF retroactive date: / / Our corporation is not currently enrolled.* *If your corporation is not currently enrolled, do you wish to join (the PCF is optional)? Yes Requested effective date: / / PCF retroactive date requested: / / No If your corporation is enrolled in the PCF, the only limits option available is $100K/$300K. The PCF limits will apply excess of your policy with us. D. Pennsylvania: Note: Although not defined as health care providers, licensed Pennsylvania professional corporations, professional associations and partnerships must participate in the Medical Care Availability and Reduction of Error (MCARE) Fund if they (1) are entirely owned by health care providers, and (2) elect to purchase basic insurance coverage. Our licensed Pennsylvania corporation is currently enrolled in MCARE. MCARE retroactive date: / / Our licensed Pennsylvania corporation is not currently enrolled in MCARE Please enroll the entity. MCARE retroactive date will be the effective date of your policy with us. The only limits option available to you through us for Pennsylvania activities is $500K/$1.5M. The MCARE limits of $500K/$1.5M will apply excess of your policy with us. IMPORTANT NOTE: The corporation may not share limits of liability with employees or any medical professionals. Podiatry Insurance Company of America Page 3 of 6

4 5. Warnings and Acknowledgements If you perform any procedures outside of the state scope of practice, they will not be covered by this policy. Fraud Warning Notices Please read the fraud warning notice below for your state. Applicant s Representations and Authorization The information provided in this application is true, complete and accurate to the best of my knowledge. I know of no other relevant facts which might affect the Company s judgment when considering this application or which might be material to the Company s risk. I also understand that any material misstatements or failure to report information which is material to the issuance of coverage may be used as a basis for rescission of my insurance and/or denial of payment of a claim. I authorize the release of any underwriting and/or claim information from all prior and current insurers, all professional societies or associations, any hospitals, or any state licensing authority, and consent to any inquiry and investigation through the use of any means legally available to Podiatry Insurance Company of America(PICA) and its subsidiaries or agents. I understand that no coverage will be bound until after PICA has reviewed my completed application and expressed its intention to provide coverage. Acceptance of payment is not an expression by PICA of intent to provide coverage. If PICA declines to offer coverage, my advance payment will be promptly returned to me. I understand that third-party information, records or data regarding my medical procedures and/or patient hours may be used for informational or underwriting purposes. I understand that should any incident, injury or death occur to any patient while under my care subsequent to my signing and dating this application, I must notify PICA or their authorized agent or broker in writing of such event. IMPORTANT NOTE: This policy does not extend to your practice outside of the United States, its territories or possessions unless any suit filed as a result of your professional services is brought against you in the United States. General Fraud Warning: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof. Arkansas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kansas: Any person who knowingly and with intent to defraud any insurance company or other person by presenting any written statement as part of an application for insurance, the rating of an insurance policy, or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto has committed a fraudulent insurance act. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Podiatry Insurance Company of America Page 4 of 6

5 Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits. Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, may be guilty of insurance fraud. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. The undersigned is authorized to complete and sign this application on behalf of the corporation. Printed Name/Title Signature of Authorized Representative Date WRITTEN APPLICATION SUBMISSION Podiatry Insurance Company of America ATTN: Policy Services 3000 Meridian Boulevard, Suite 400 Franklin, TN ELECTRONIC APPLICATION SUBMISSION Fax: or policyservices@picagroup.com Podiatry Insurance Company of America Page 5 of 6

6 Supplementary Claims Information Form If there has been more than one claim, please photocopy this form. Attach additional sheets if needed. All questions must be answered or marked Not Applicable (N/A). 1. Patient s Name: 2. Date Reported to Insurance Company: 3. Name of Insurance Company: 4. Name and Address of the Attorney Assigned to Your Case: 5. Date of Incident and Your Treatment: 6. Allegations: 7. What is the present condition of the patient? 8. Did you in any way alter, embellish, delete, change, and/or destroy any records, medical or otherwise, or were allegations made that you did so, pertaining to this claim? Yes No 9. Status of claim (check applicable answer): Suit threatened, no action taken Court outcome in your favor Awaiting mediation Suit filed, but dropped by claimant Jury verdict Awaiting court action Summary judgment in your favor Directed verdict Reserve Amount: Suit settled out-of-court Court outcome in favor of plaintiff Date claim paid: Jury verdict Amount paid: Directed verdict Amount of Loss: 10. To your knowledge, was any settlement paid by another party involved (i.e., your PA, PC, partners, employees, etc.)? Yes No If yes, amount paid: $ Name (Printed): Signature: Date: Podiatry Insurance Company of America Page 6 of 6