Malpractice Insurance For Allied Healthcare Professionals

Transcription

1 Malpractice Insurance For Allied Healthcare Professionals 1) Please print a copy of this application to your desktop printer. 2) Complete this hard copy by hand, answering all questions 3) Sign, date and either: a. Mail your completed application providing your credit card information OR with check payable to: CM&F Group, Inc., 99 Hudson Street, 12th Floor, New York, NY OR b. Fax your signed and completed application providing your credit card information (per the application) to CM&F Group, Inc. at (212) ) Once your application is processsed, you will be notified by within 5-7 business days of confirmation of coverage. Your payment --- whether by check or credit card -- will NOT be processed until your coverage has been approved.

2 Class Definitions Professional Class I Occupational Therapist Occupational Therapist Assistant Certified OT Assistant Respiratory Care Provider Respiratory Therapist Respiratory Therapist Technician/Technologist Professional Class II Art Therapist Dance Therapist Diagnostic Medical Sonographer Horticultural Therapist Music Therapist Recreation Therapist Professional Class III Audiologist Bio-Medical Technician/Technologist Blood Bank Technician/Technologist Cardiology Technician/Technologist Certified Laboratory Technician/Technologist Certified Medical Assistant Clinical Laboratory Technician/Technologist Community Health Assistant Community Health Technician/Technologist Dialysis Technician/Technologist Dietitian EEG Technician/Technologist Electrologist Health Educator Histologic Technician/Technologist Laboratory Aide Medical Laboratory Technician/Technologist Medical Technician Medical Technician/Technologist Assistant Medical Technologist Medical Assistant Medical Records Administrator Medical Records Technician/Technologist Nuclear Medical Technician/Technologist Nutritionist Phlebotomist Radiation Therapist Radiologic Technician/Technologist Speech Hearing Therapist Speech Language Pathologist Surgeon Assistant Surgical Technician/Technologist X-Ray Machine Operator Professional Class IV Medical Dosimetrist Pharmacist Pharmacist (Consulting) Professional Class V Circulation Technician/Technologist Rehabilitation Assistant Rehabilitation Therapist Professional Class VI Corrective Therapist Enterostomal Therapist Exercise Physiologist Kinesiologist/Kinesiotherapist Massage Therapist Orthopedic Assistant Wellness Counselor Professional Class VIIA Athletic Trainer (Non-medical, Non-certified) Professional Class VIIB Athletic Trainer (Medical, LPT or RPT) Professional Class VIIC Electroneurodiagnostic Technician Professional Class VIIIA Student/Volunteer EMT Professional Class VIIIB Basic/Intermediate EMT Professional Class VIIIC Paramedic Professional Class IX A - Physical Therapist B - PT Assistant Professional Class X Sports Medicine Instructor Sports Medicine Therapist

3 Rate Chart By Class Definitions Alabama, Alaska, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Hawaii, Idaho, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, Washington D.C., Wisconsin & Wyoming I $88 $263 II $98 $293 III $102 $102 IV $128 $384 V $173 $173 VI $202 $202 VIIA $202 $607 VIIB $405 $1,212 VIIC $607 $607 VIIIA $91 $91 VIIIB $224 $224 VIIIC $271 $271 IXA $260 $260 IXB $130 $130 X $363 $363 I $71 $214 II $79 $238 III $83 $83 IV $104 $311 V $141 $141 VI $164 $164 VIIA $164 $493 VIIB $328 $985 VIIC $493 $493 VIIIA $74 $74 VIIIB $182 $182 VIIIC $220 $220 IXA $211 $211 IXB $106 $106 X $294 $294 Arizona I $97 $290 II $107 $322 III $113 $113 IV $141 $422 V $191 $191 VI $223 $233 VIIA $233 $668 VIIB $445 $1,335 VIIC $668 $668 VIIIA $100 $100 VIIIB $247 $247 VIIIC $298 $298 IXA $286 $286 IXB $143 $143 X $399 $399 I $78 $235 II $87 $262 III $91 $91 IV $114 $343 V $155 $155 VI $181 $181 VIIA $181 $542 VIIB $361 $1,084 VIIC $542 $542 VIIIA $81 $81 VIIIB $200 $200 VIIIC $242 $242 IXA $233 $233 IXB $116 $116 X $324 $324 Kentucky residents only: Add $1.50 surcharge New Jersey residents only: Add.9% surcharge

4 Rate Chart By Class Definitions Georgia I $86 $258 II $96 $287 III $100 $107 IV $125 $376 V $170 $170 VI $198 $198 VIIA $198 $594 VIIB $396 $1,189 VIIC $594 $594 VIIIA $89 $89 VIIIB $220 $220 VIIIC $265 $265 IXA $255 $255 IXB $128 $128 X $355 $355 I $71 $209 II $78 $233 III $81 $81 IV $102 $304 V $138 $138 VI $161 $161 VIIA $161 $483 VIIB $322 $965 VIIC $483 $483 VIIIA $72 $72 VIIIB $178 $178 VIIIC $215 $215 IXA $207 $207 IXB $104 $104 X $288 $288 Maryland I $76 $213 II $85 $256 III $89 $89 IV $111 $312 V $150 $150 VI $175 $175 VIIA $175 $526 VIIB $351 $1,053 VIIC $526 $526 VIIIA $79 $79 VIIIB $195 $195 VIIIC $236 $236 IXA $227 $227 IXB $113 $113 X $315 $315 I $62 $171 II $69 $206 III $72 $72 IV $90 $251 V $121 $121 VI $141 $141 VIIA $141 $424 VIIB $282 $847 VIIC $424 $424 VIIIA $64 $64 VIIIB $157 $157 VIIIC $190 $190 IXA $182 $182 IXB $91 $91 X $253 $253

5 Rate Chart By Class Definitions Indiana I $88 $263 II $89 $293 III $102 $102 IV $128 $384 V $173 $173 VI $202 $202 VIIA $202 $607 VIIB $405 $1,214 VIIC $607 $607 VIIIA $91 $91 VIIIB $224 $224 VIIIC $271 $271 IXA $260 $260 IXB $130 $130 X $363 $363 I $71 $214 II $79 $238 III $83 $83 IV $104 $311 V $141 $141 VI $164 $164 VIIA $164 $493 VIIB $328 $985 VIIC $493 $493 VIIIA $74 $74 VIIIB $182 $182 VIIIC $220 $220 IXA $211 $211 IXB $106 $106 X $294 $294 $250,000/$750,000 Rates I $63 $189 II $70 $210 III $74 $74 IV $92 $276 V $124 $124 VI $145 $145 VIIA $145 $436 VIIB $291 $872 VIIC $436 $436 VIIIA $65 $65 VIIIB $161 $161 VIIIC $195 $195 IXA $187 $187 IXB $94 $94 X $261 $261 New York I $89 $235 II $98 $295 III $103 $103 IV $129 $386 V $174 $174 VI $204 $204 VIIA $204 $611 VIIB $407 $1,221 VIIC $611 $611 VIIIA $91 $91 VIIIB $226 $226 VIIIC $273 $273 IXA $262 $262 IXB $131 $131 X $365 $365 I $71 $215 II $80 $239 III $84 $84 IV $104 $313 V $142 $142 VI $165 $165 VIIA $165 $496 VIIB $331 $992 VIIC $496 $496 VIIIA $74 $74 VIIIB $183 $183 VIIIC $221 $221 IXA $213 $213 IXB $106 $106 X $296 $296

6 Rate Chart By Class Definitions West Virginia I $88 $265 II $98 $295 III $103 $103 IV $129 $386 V $174 $174 VI $204 $204 VIIA $204 $611 VIIB $407 $1,222 VIIC $611 $611 VIIIA $91 $91 VIIIB $226 $226 VIIIC $273 $273 IXA $262 $262 IXB $131 $131 X $365 $365 I $72 $215 II $80 $240 III $84 $84 IV $105 $314 V $142 $142 VI $165 $165 VIIA $165 $496 VIIB $331 $992 VIIC $496 $496 VIIIA $74 $74 VIIIB $183 $183 VIIIC $221 $221 IXA $213 $213 IXB $106 $106 X $ Texas I $110 $329 II $122 $366 III $128 $128 IV $160 $480 V $217 $217 VI $253 $253 VIIA $253 $759 VIIB $506 $1,517 VIIC $759 $759 VIIIA $113 $113 VIIIB $280 $280 VIIIC $339 $339 IXA $326 $326 IXB $163 $163 X $453 $453 I $89 $267 II $99 $297 III $104 $104 IV $130 $389 V $176 $176 VI $205 $205 VIIA $205 $616 VIIB $411 $1,232 VIIC $616 $616 VIIIA $92 $92 VIIIB $228 $228 VIIIC $275 $275 IXA $264 $264 IXB $132 $132 X $368 $368

7 Mail Completed Application To: CM&F Group, Inc. 99 Hudson Street, 12th Floor New York, New York (212) (800) Fax (212) GENERAL HEALTHCARE PROVIDER PROFESSIONAL LIABILITY Allied Health Application (1/00) Underwritten By: Granite State Insurance Company (A Capital Stock Company) 2704 Commerce Drive, Suite B Harrisburg, PA First Name Middle Initial Last Name Street Address Apartment No. City County State Zip Code Social Security # Telephone # Fax # Address Professional License # 2. How did you hear about us? Convention Colleague Advertisement Mail CM&F Group Website Association (Please List) Other 3. I am: self-employed an employee 4. Please indicate your profession from the Class Definitions show below: CLASS DEFINITIONS Professional - Class I Occupational Therapist Occupational Therapist Assistant Certified OT Assistant Respiratory Care Provider Respiratory Therapist Respiratory Therapist Technician/Technologist Professional - Class III Audiologist Bio-Medical Technician/Technologist Blood Bank Technician/Technologist Cardiology Technician/Technologist Certified Laboratory Technician/Technologist Certified Medical Assistant Clinical Laboratory Technician/Technologist Community Health Assistant Community Health Technician/Technologist Dialysis Technician/Technologist Dietitian EEG Technician/Technologist Electrologist Health Educator Histologic Technician/Technologist Laboratory Aide Medical Laboratory Technician/Technologist Professional - Class IV Medical Dosimetrist Pharmacist Pharmacist (Consulting) Professional - Class VI Corrective Therapist Enterostomal Therapist Exercise Physiologist Kinesiologist/Kinesiotherapist Massage Therapist Orthopedic Assistant Wellness Counselor Professional - Class II Art Therapist Dance Therapist Diagnostic Medical Sonographer Horticultural Therapist Music Therapist Recreation Therapist Medical Technician Medical Technician/Technologist Assistant Medical Technologist Medical Assistant Medical Records Administrator Medical Records Technician/Technologist Nuclear Medical Technician/Technologist Nutritionist Phlebotomist Radiation Therapist Radiologic Technician/Technologist Speech Hearing Therapist Speech Language Pathologist Surgeon Assistant Surgical Technician/Technologist X-Ray Machine Operator Professional - Class V Circulation Technician/Technologist Perfusionist Rehabilitation Assistant Rehabilitation Therapist

8 Professional - Class VIIA Athletic Trainer (Non-medical, Non-certified) Professional - Class VIII A Student/Volunteer EMT Professional - Class VIII C Paramedic Professional - Class X Sports Medicine Instructor Sports Medicine Therapist Professional - Class VIIB Athletic Trainer (Medical, LPT or RPT) Professional - Class VIII B Basic/Intermediate EMT Professional - Class IX A- Physical Therapist B- PT Assistant Professional - Class VIIC Electroneurodiagnostic Technician *NOTE: This program does not cover psychologists, dental students, medical students or mental health counselors. 5. Please indicate desired (please check one): $500,000/$1,00,000 $1,000,000/$6,000,000 Are you an Indiana Resident electing to participate in the Indiana Patient s Compensation Fund? If yes, your Limit of Liability will be $250,000/$750,000 Yes No 6. Have you ever been the subject of a reprimand or disciplinary action or refused employment or admission to a professional society or had your professional privileges suspended by any court or administrative agency or ever been the subject of any ethics investigation at a local, state or national level? Yes No If yes, please attach a separate sheet with full particulars. 7. Has any insurance ever been cancelled or non-renewed? *NOTE: Missouri Residents Do Not Respond. Yes No 8. Has any malpractice claim or suit ever been brought against you? Yes No If yes, please attach a separate sheet with full particulars. 9. Are you aware of any circumstances which may result in a malpractice claim or suit being made or brought against you? Yes No If yes, please attach a separate sheet with full particulars. 10. Please list your prior professional liability insurance, if any. INSURANCE POLICY LIMITS PREMIUM EFFECTIVE CARRIER NUMBER DATES The undersigned declares that the statements set forth herein are true. The undersigned agrees that if the information supplied on this application changes between the date of this application and the effective date of the insurance, he/she (undersigned) will immediately notify the company of such changes, and the company may withdraw or modify any outstanding quotations, authorization or agreement to bind the insurance. Signing of this application does not bind the applicant or the company to complete the insurance, but it is agreed that this application shall be the basis of the contract should a policy be issued, and it will be attached to and become a part of the policy. All written statements and materials furnished to the company in conjunction with the application are hereby incorporated by reference into the application and made a part hereof. The earliest effective date in which a policy can be issued is the date this application is received in our office. NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSUR- ANCE 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 ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO ARKANSAS AND NEW MEXICO APPLICANTS: 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. NOTICE TO COLORADO APPLICANTS: 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 POL- ICYHOLDER 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 AUTHORITIES. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUD- ING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFOR- MATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT. NOTICE TO FLORIDA APPLICANTS: 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 IN THE THIRD DEGREE.

9 NOTICE TO KENTUCKY APPLICANTS: 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 THERE- TO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRES- ENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO MAINE APPLICANTS: 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 A DENIAL OF INSURANCE BENEFITS. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW YORK APPLICANTS: 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. NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLI- CATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. NOTICE TO OKLAHOMA APPLICANTS: 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 (365: , ). NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICA- TION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CON- CERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO TENNESSEE AND VIRGINIA APPLICANTS: 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 Applicant s Signature: Title: Date: Name of Agent: Submitted by: Date: Address: Florida Agent License #: California Agent License #: (1/00) PREPAYMENT REQUIRED Check or money order enclosed. I authorize CM&F Group, Inc. to charge the premium to my: VISA MASTERCARD Credit Card Account Number: Print name exactly as it appears on card: Charge premium to credit card. Expiration Month and Year: THIRD PARTY CREDIT CARD AUTHORIZATION CHARGE TO: VISA MASTERCARD Credit Card Account Number: Card Member Name (Print): Signature: Please complete the following (if payer other than applicant): Expiration Month and Year: Date Signed: MAIL TO: CM&F Group, Inc. 99 Hudson Street, 12th Floor, New York, NY FAX: info@cmfgroup.com Florida Applicants: Richard J.J. Sullivan, Jr. Non Resident License #A California Applicants: CMF Group, Inc. Non Resident CA License #OC