Dental Professional Liability Insurance Application Form

Transcription

1 Dental Professional Liability Insurance Application Form With your completed application, you must submit the following information: 1. Current declarations page 2. Written verification of the purchase of a reporting endorsement from your present carrier if your current coverage is claims-made and you are not applying for prior acts coverage 3. Current business letterhead ProAssurance Indemnity Company, Inc. P.O. Box Madison, WI MA-DA KS 2000 ProAssurance Corporation

2 Please indicate your desired level of coverage by placing an X in the appropriate box. Excess coverage limits are not required but are recommended. PRIMARY COVERAGE LIMITS Limit Per Claim / Annual Aggregate Limit Plus $1,000,000 $ 200,000 / $ 600,000 $ 500,000 / $1,000,000 $2,000,000 $1,000,000 / $2,000,000 $1,000,000 / $3,000,000 $3,000,000 $4,000,000 Note: Excess limits are not offered above underlying limits of less than $1,000,000/$3,000,000. Requested Effective Date: / / Month Day Year Coverage will become effective upon the completion of all underwriting functions and acceptance by the Company. Note: If any space provided herein is insufficient for complete reply, please use page 9 or attach a separate sheet, identifying by number the question to which you are replying. 1. Full Name of Applicant: First Middle Last 2. Social Security Number: 3. Date of Birth: Place of Birth: 4. Home Address: Telephone Number: ( ) - Street Address City State ZIP Address (if applicable): 5. Principal Office Address: Street Address City State ZIP Office Phone Number: ( ) - Office Fax Number: ( ) - Please check this box if your Principal Office Address is not actually located within the city limits of the city to which your mail is addressed, and indicate the city or county in which your office is located: City County 6. Secondary Office Locations (if any): Telephone Number: ( ) - Street Address City State ZIP Street Address City State ZIP ( ) - 7. Preferred Billing Address: Principal Office Secondary Office Home 8. In which states are you licensed to practice dentistry? Member of State License Number % of Practice State Dental Association Which County? Yes Yes Yes No No No MA-DA KS 2000 ProAssurance Corporation Page 2 of 10

3 GENERAL INFORMATION Please provide the name of your current or previous Professional Liability Insurance carrier and the date on which your current Professional Liability Insurance policy expired or will expire: Name of Insurer / / Policy Expiration Date 9. Have you ever applied to a ProAssurance company for insurance before? Yes No 10. If you have been insured under a claims-made policy, are you requesting that the Company provide prior acts coverage? Yes No Important: If you are not applying for prior acts coverage and are not purchasing a reporting endorsement from your current carrier, please explain why on page 9 and/or a separate sheet of paper. Note: If any of the following questions are answered yes, please submit a complete explanation using page 9 and/or a separate sheet of paper. 11. Has any insurance company (including Lloyds of London) ever canceled, declined to issue, refused to renew, surcharged your premium, or issued coverage with any restrictions or exclusions? (This question is not applicable in Missouri.) Yes No Important information regarding questions 12 and 13, including sub-questions: The word claim as used in questions 12 and 13 below refers to: A. Any 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; or B. Circumstances which have been brought to your attention by a patient or representative of a patient in such a manner as to indicate the possibility of legal action against your or any partner, associate, employee, or professional corporation or partnership. If you answer yes to questions 12 and/or 13, including sub-questions, please complete the attached Supplementary Claims Information Form (page 10). 12. Have you ever been involved in a malpractice claim or suit, either directly or indirectly? Yes No 13. Are you aware of any of the following circumstances that might reasonably lead to a claim or suit being brought against you even if you believe the claim or suit would be without merit? Yes No A. A request for records from a patient and/or attorney related to an adverse outcome? Yes No B. A letter from an attorney regarding your medical treatment of a patient? Yes No C. Intra-operative or post-operative complications or other complications resulting in death, paralysis, or other significant disabilities? Yes No D. Patient or family member dissatisfaction with the outcome of a procedure, treatment, or diagnosis? Yes No E. Any other circumstances that might reasonably lead to a claim or suit? Yes No Have all circumstances that might reasonably lead to a claim or suit (even if you believe the possible claim or suit would be without merit) been reported to your current or prior professional liability carrier? Yes N/A* No If yes, how many? Please attach documentation of all such reports. If no, please explain on page 9. *For purposes of this question, N/A means that you are aware of no circumstances that might reasonably lead to a claim or suit. 14. Has your license to practice dentistry or your permit to prescribe drugs ever been denied, revoked, suspended, voluntarily surrendered, or otherwise investigated or limited in any way? Yes No 15. Have your hospital staff privileges ever been suspended, revoked, voluntarily surrendered, or in any other way restricted? Yes No 16. Have you ever failed any licensing or Board Certification examinations? Yes No 17. Have you ever been refused hospital privileges? Yes No 18. Have you ever appeared before, been investigated by, or entered into any consent agreement with any formal hospital committee, state licensing Board, Board of Dental Examiners, or other dental review committee? Yes No MA-DA KS 2000 ProAssurance Corporation Page 3 of 10

4 19. Have you ever had a patient or patient representative complain to or file a grievance of any type with a hospital committee, state licensing Board, Board of Dental Examiners, or other dental review committee? Yes No 20. Have you ever been convicted of a violation of any law or ordinance other than traffic offenses (but including driving while under the influence of alcohol)? Yes No 21. Have you ever been evaluated or recommended for treatment for, diagnosed with, or treated for alcohol, narcotics, or any other substance abuse, sexual addiction, or mental illness? Yes No 22. Do you have any physical handicap or chronic illness? Yes No PRACTICE INFORMATION 23. Your practice or primary specialty: General Practitioner Oral Surgeon Periodontist Prosthodontist Endodontist Pedodontist Orthodontist Other: 24. Procedures you perform: Implants Other (list below): Extractions Root canals 25. Please list the name and location of all dental schools attended: Institution & Location Dates Attended Degree Obtained 26. Please list any post-graduate training, including dates and location: Institution & Location Dates Attended Degree Obtained 27. Please list all locations where you have practiced and the dates practiced there: Location Dates Practicing at This Location Note: Any interim periods of time during which you did not practice dentistry should be explained on a separate sheet of paper. 28. Coverage Desired for (check all that apply): A. Solo Entity Name: Separate Limits (Available only in Alabama) Shared Limits Member of a partnership or multi-shareholder corporation: Partnership/Group Name: Separate Limits Shared Limits Other (e.g., implied partnership, corporation, etc.): Entity Name: Separate Limits Shared Limits MA-DA KS 2000 ProAssurance Corporation Page 4 of 10

5 B. Give the full names of all other dentists affiliated with any organization(s) named in question 28A. All dental members or employees must complete a separate application if organization coverage is to be provided. Use page 9 and/or additional sheets if needed. Name Current Dental Professional Liability Insurance Company 29. I hereby make application for the insurance coverage(s) checked below: Individual Professional Liability Partnership-Corporation-Professional Association Liability Please indicate below the number of employees in your practice: # Dental Assistants # Nurses # Dental Hygienists # Surgical Assistants # Laboratory Technicians # Other (specify): Please indicate the number of miscellaneous dental professionals in your employ: Indicate whether certified or OJT: 30. Note: This question inquires as to your use of anesthetics and analgesia. Make certain you read and answer all parts very carefully. If you administer general anesthesia in any form, please also complete the General Anesthesia Questionnaire following this question. A. Do you limit your practice to local anesthesia and/or oral medication? Yes No B. Do you treat patients who have been subjected to Nitrous Oxide or who have been administered any other form of inhalation sedation? Yes No If yes, is this done in-office, hospital, or outpatient clinic? C. Do you treat patients who have been administered any form of intravenous sedation or intramuscular sedation? Yes No If yes, is this done in-office, hospital, or outpatient clinic? D. Do you treat patients who have been rendered unconscious by any form of general anesthesia? Yes No If yes, is this done in-office, hospital, or outpatient clinic? E. Please briefly describe below your use of anesthetics, both local and general. Also describe your use of any type of analgesia. MA-DA KS 2000 ProAssurance Corporation Page 5 of 10

6 GENERAL ANESTHESIA QUESTIONNAIRE 31. How many times per week do you use general anesthesia in your office? Over to 20 5 to 10 Less than How long have you used general anesthesia on a daily basis? Over 10 years 3 to 10 years Less than 3 years Not used daily 33. What type(s) of anesthesia do you use? Local Inhalation Intravenous Combination 34. What types of oral surgery do you perform? Minor (Alveolar) Major (other procedures) 35. Where do you perform procedures? Office Hospital Office and Hospital 36. How many of the following employees does your operating team include? # Office-trained Dental Assistants # Nurse Anesthetists # Other Dentists or M.D.s # Surgical Assistants # Registered Nurses # Licensed Practical Nurses # Other: 37. Are you equipped and trained to use positive pressure endotracheal respiratory assistance? Yes No 38. Do you intubate patients for airway maintenance under general anesthesia? Yes No If yes, how often per month? 39. How many months of university or hospital training in general anesthesia/analgesia do you have? Over 12 months 6 to 12 months 3 to 6 months Less than 3 months 40. Have you participated in an office Self Evaluation Program of your peers in the past 5 years? Yes No 41. Please indicate your certification information: ACLS Certified BCLS Certified Not Certified 42. Please list the names of others in your office that are certified and specify ACLS or BCLS. Full Name of Employee Type of Certification 43. Please indicate the types of equipment available and properly maintained in your office: (a) ECG (b) Anesthesia Machine (c) Oxygen Source (d) Defibrillator (e) AMBU Bag (f) Suction Apparatus (g) Intubation Equipment (h) Temperature Monitor (i) IV Set Up (j) BP Monitor (k) Resuscitative & Emergency Drugs (Crash Cart) MA-DA KS 2000 ProAssurance Corporation Page 6 of 10

7 Important! You Must Read Carefully COLORADO FRAUD WARNING: 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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. FLORIDA FRAUD NOTICE: 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. KENTUCKY FRAUD WARNING: 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. NEW JERSEY FRAUD WARNING: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NEW YORK FRAUD WARNING: 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 FRAUD WARNING: 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 FRAUD 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. PENNSYLVANIA FRAUD WARNING: 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. WISCONSIN EXCEPTION: If the company agrees to be bound under the terms of this application, your policy will be cancelled if you hide any important information from us, or attempt to defraud or lie to us about any matter contained in this application. SPECIFIC CONSENT TO CONDITIONS OF CONSIDERATION OF THE APPLICATION FOR INSURANCE With the submission of this application for insurance, I accept the following conditions during the processing and consideration of my application regardless of whether or not I am granted insurance and for the duration of the insurance which may be issued to me: To the fullest extent permitted by law, I extend absolute immunity to, and release ProAssurance Indemnity Company, Inc., its directors, officers, agents, employees, and other authorized representatives from any and all liability for any acts pertaining to my application for insurance, including ultimate cancellation, rejection, or approval for insurance, and any communications, reports, records, statements, documents, or disclosures, including otherwise privileged or confidential information, made or given in good faith with respect to such application. I acknowledge that acceptance into ProAssurance Indemnity Company, Inc. s insurance program is not a right of every licensed dentist who makes application for insurance, and that my application will be evaluated by authorized management personnel and/or the Company s Underwriting Committee. Applicant s Signature Date Important: Incomplete or incorrect information could require retroactive upward premium adjustment, and in the event of a claim, could lead to a denial of liability. The following page of this Application is an Authorization to Release Information form which requires your signature. Please read carefully. MA-DA KS 2000 ProAssurance Corporation Page 7 of 10

8 AUTHORIZATION TO RELEASE INFORMATION The undersigned applicant for insurance by ProAssurance Indemnity Company, Inc. (the "Company") hereby authorizes his present and prior professional liability insurance carriers and any and all attorneys who have represented the undersigned in connection with any claim of professional liability to release to the Company upon its request information regarding closed, pending, or anticipated claims and any underwriting or other information which in the judgment of any such carrier, attorney, or the Company may have a bearing upon his acceptability to the Company as a professional liability insurance risk. The undersigned also authorizes all dental associations and dental societies in which he is or has been a member, all hospitals in which he now holds or has held staff privileges, the State Board of Dental Examiners for any state in which he has practiced, or resided, and any and all dentists or any other third party having information regarding the undersigned, to release to the Company upon its request any information any such person or entity may have which in the judgment of any such person or entity or the Company may have a bearing upon his acceptability to the Company as a professional liability insurance risk. The undersigned hereby releases and agrees to hold harmless all persons or organizations releasing the information described above, their agents, servants, and employees, and the Company, its directors, officers, employees, agents, and members from any liability arising out of the release or use of any information released or furnished pursuant to this authorization, notwithstanding the fact that there may be errors, omissions, or mistakes contained in such released information. The undersigned further agrees that the Company and all persons and organizations described above may rely upon a photostatic copy of this Authorization, which shall be of equal validity with the signed original. Name (printed): Signature: Address: Date: MA-DA KS 2000 ProAssurance Corporation Page 8 of 10

9 Additional Comments MA-DA KS 2000 ProAssurance Corporation Page 9 of 10

10 Dentists 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. Date of Incident and Your Treatment: 5. Allegations: 6. What is the present condition of the patient? 7. 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 8. Status of Claim (check applicable answer): Suit threatened, no action taken Suit filed but dropped by claimant Summary judgment in your favor Suit Settled Out-of-Court: a. Date Claim Paid: b. Amount Paid: $ c. Did you want to settle this claim? Yes No Awaiting Mediation Awaiting Court Action a. Reserve Amount: $ Court outcome in your favor: Jury Verdict Directed Verdict Court outcome in favor of plaintiff: Jury Verdict Directed Verdict Amount of Loss Payment: $ 9. Name and address of the attorney assigned to your case: 10. To your knowledge, was any settlement paid by another party involved (e.g., your P.A., P.C., partners, employees, etc.)? Yes No If yes, amount was: $ Signature: Date: Name (printed): MA-DA KS 2000 ProAssurance Corporation Page 10 of 10