Your application must be in our office at least 30 days prior to your desired effective date

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1 ATTENTION: Indiana Licensed Healthcare Providers PLEASE NOTE: The state of Indiana has established a Professional Liability insurance pool called the Indiana Patient Compensation Fund (INPCF). The following occupations are eligible to participate: Nurse Occupational Therapist Optometrists Psychologist Physical Therapist Nurse Practitioner Respiratory Care Therapist Physician Assistant As your insurance administrator, we will enroll you and/or your employees in the INPCF. The INPCF requires you to carry limits of $250,000 per incident and $750,000 policy aggregate on your Primary Professional Liability Insurance Policy. This basic coverage would protect you against Professional Liability suits up to the point where the fund takes over. (A surcharge is added to the premium for inclusion in the fund.) If you choose to participate in the Patient Compensation Fund (INPCF), we will need the attached application and staff roster completed to enroll in the INPCF. Once this information is received in our office and approved, you will be sent a premium quotation. PLEASE DO NOT SEND PREMIUM AT THIS TIME. Please mail your completed application and staff roster to the following address: M Consumer PO Box Des Moines, IA You may also fax these documents to: If you do not choose to participate in the Patient Compensation Fund, simply complete the enclosed application along with premium payment and fax or mail your application to the address indicated on the application. Your application must be in our office at least 30 days prior to your desired effective date If you have any questions concerning the details of the Patient Compensation Fund, please contact the Indiana Dept of Insurance Medical Malpractice Division 311 West Washington, Suite 300 Indianapolis, IN Website: idoi@in.gov October 2010 Stock:

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3 Private Practice Section - APTA APTA PROFESSIONAL LIABILITY INSURANCE APPLICATION Underwritten by Liberty Insurance Underwriters Inc. HOW TO APPLY: 1. Complete application below. 2. Note the premium below for the policy you selected. All premiums are annual. 3. Return your completed application, along with your annual premium, to the address provided. All coverages elected must be under the same policy limits. Coverage is effective the date your application is approved and payment is received. Please allow three to four weeks for delivery of your certificate. Please print or type all information. Visit for more information and to view available professions for applying online. RESIDENTS OF INDIANA ONLY Do you desire to participate in the Indiana Patient Compensation Fund (INPCF)? q Yes (If yes, complete the application and INPCF Roster of Professional Staff. Do not submit premium at this time, you will receive a quote from our underwriting department once your application is received and reviewed.) q No (If no, complete the application, submit premium to the address on the last page of this application.) 1. APPLICANT INFORMATION (All applicants must complete. Please print all information.) INDIVIDUAL APPLICANTS: FIRST NAME INITIAL LAST NAME BUSINESS APPLICANTS: CORPORATE NAME / DBA / YOUR NAME, IF NOT INCORPORATED (COMPLETE ONLY IF YOU OWN THE BUSINESS) BUSINESS APPLICANTS: NAMES OF OWNERS, PARTNERS AND CORPORATE OFFICERS WHO ARE ACTIVE IN THE BUSINESS AND THEIR PROFESSIONAL OCCUPATION PHYSICAL STREET ADDRESS (MUST COMPLETE) CITY STATE ZIP MAILING ADDRESS (IF DIFFERENT THAN ABOVE) CITY STATE ZIP BUSINESS PHONE# FAX # HOME PHONE # ADDRESS WEBSITE ADDRESS 2. DEFINITIONS Employed means you receive a W-2 and are not an owner of the legal entity that issues your W-2. Individual Employed coverage is not available if you have employees or independent contractors working on your behalf. Self-Employed is a professional who functions full or part-time as an independent agent with private patients, or as the owner of a business, paid on a fee-for-service basis. 3. EMPLOYED INDIVIDUALS ANNUAL LIMITS AND PREMIUMS $2,000,000 per incident/occurrence $1,000,000 per incident/occurrence $4,000,000 annual aggregate $3,000,000 annual aggregate Professional Designation q Employed Physical Therapist q $213 q $182 q Employed Physical Therapist Assistant q $94 q $80 S.C. WWW HCPAPP-1000 (Ed.01/2010) 1BE SURE TO COMPLETE ALL PAGES AND SIGN LAST PAGE 1 Stock:

4 4. UNDERWRITING DATA - EMPLOYED INDIVIDUAL APPLICANTS ONLY (Required for employed applicants - please answer all questions to prevent underwriting delays.) (Attach an explanation for all YES responses on a separate sheet of letterhead.) 1. Have you or any of your employees ever had the following: revoked, suspended, refused, denied renewal, placed on probation, cancelled, or voluntarily surrendered by you or any of your employees or is such an action pending? (If Yes, explain on a separate sheet of paper, please include dates and details.) State License or Certification q YES q NO Malpractice Insurance q YES q NO 2. Has any claim or suit ever been brought against you or any of your employees or are you or any of your employees aware of any incident that might reasonably lead to a claim or suit? (If Yes, explain on a separate sheet of paper, please include dates, allegations and amounts.) q YES q NO EMPLOYED INDIVIDUALS PROCEED TO DECLARATION AND SIGNATURE. 5. SELF-EMPLOYED INDIVIDUALS & BUSINESS APPLICANTS ANNUAL LIMITS AND PREMIUMS $2,000,000 per incident/occurrence $1,000,000 per incident/occurrence $4,000,000 annual aggregate $3,000,000 annual aggregate Professional Designation A. A premium must be paid for all owners, partners and principals active in the business. q Self-Employed Physical Therapist ( ) x $674 = $ ( ) x $576 = $ q Self-Employed Physical Therapy Assistant/Aide ( ) x $316 = $ ( ) x $270 = $ q Other (Owner who is not one of the above professions) ( ) x $ = $ ( ) x $ = $ (Please specify occupation and contact administrator for premium) B. A premium must be paid for each employee. q Physical Therapist(s) ( ) x $439 = $ ( ) x $375 = $ q Athletic Trainer(s) ( ) x $439 = $ ( ) x $375 = $ q Massage Therapist(s) ( ) x $439 = $ ( ) x $375 = $ q Occupational Therapist(s) (OTR & COTA) ( ) x $439 = $ ( ) x $375 = $ q Physical Therapy Assistants/Aides ( ) x $439 = $ ( ) x $375 = $ q Nurse(s) (Excluding NP & CNS w/pda) ( ) x $439 = $ ( ) x $375 = $ q Speech/Hearing Therapist(s) ( ) x $439 = $ ( ) x $375 = $ q Other Employee: ( ) x $439 = $ ( ) x $375 = $ (Please specify occupation) C. A premium must be paid for each independent contractor. q Independent Contractors ( ) x $59 = $ ( ) x $50 = $ NOTE: This policy covers vicarious liability claims made against you or your business as a result of professional services rendered by an Independent Contractor working under your direction. To reduce your exposure, you should annually require and verify that all Independent Contractors purchase and maintain their own professional liability policy. Be advised that your policy will not directly or indirectly defend any Independent Contractor(s). The number of contractors used above in determining premium must equal the number answered in Section 11, Question 12 (c). HCPAPP-1000 (Ed.01/2010) 1BE SURE TO COMPLETE ALL PAGES AND SIGN LAST PAGE 2

5 6. OPTIONAL COVERAGES (SELF-EMPLOYED INDIVIDUALS AND BUSINESS APPLICANTS ONLY) ANNUAL LIMITS AND PREMIUMS $2,000,000 per incident/occurrence $1,000,000 per incident/occurrence $4,000,000 annual aggregate $3,000,000 annual aggregate General Liability *Please attach name and physical address for each location. (Property owned or rented by the named insured) 1st location q $140 q $120 Additional location(s) ( ) x $59 = $ ( ) x $50 = $ Additional Insured *Please attach name and physical address for each facility. (This coverage is for facilities that you maintain contracts with which REQUIRE you to add them as an additional insured on your insurance certificate.) Professional Liability Only ( ) x $146 = $ ( ) x $125 = $ General Liability Only (available only if General Liability is purchased above) ( ) x $30 = $ ( ) x $25 = $ Professional & General Liability (available only if General Liability is purchased above) ( ) x $176 = $ ( ) x $150 = $ *To prevent underwriting delays, please submit this information if coverage is required. 7. SUBTOTAL SECTIONS 5 & 6 $ $ 8. IF YOUR PRACTICE CONSISTS OF: A. TWO OR MORE PROFESSIONALS, Total of premium entered in Section 7 above X.15 = $ $ B. PROVIDE 40% OR MORE OF TREATMENT OR ASSESSMENT TO WORKERS COMPENSATION PATIENTS, Total premium entered in Section 7 above X.20 = $ $ 9. CALCULATE YOUR PREMIUM TOTAL LIABILITY PREMIUM (Add Sections 7 & 8, ROUND TO THE NEAREST WHOLE DOLLAR) $ Your individual practice risk characteristics may warrant use of a premium modification factor based upon company underwriting discretion. 10. SEPARATE ENTITY LIMITS OF LIABILITY (Optional coverage for Business Applicants Only) A separate Limit of Liability for a legal entity may be available for an additional premium. Be advised that a request for a separate Limit of Liability for an entity requires a referral to the carrier and may delay a final decision on your application, our ability to offer a firm quote, and bind coverage. The separate Limits of Liability for the entity are only available at the $1,000,000 per incident/occurrence and $3,000,000 annual aggregate level. Please check the box below if you would like to apply for separate Entity Limits of Liability. q Separate Entity Limits of Liability (Minimum Additional Premium is 17% or more of Total Premium Due, Section 9) HCPAPP-1000 (Ed.01/2010) 1BE SURE TO COMPLETE ALL PAGES AND SIGN LAST PAGE 3 Stock:

6 11. SELF-EMPLOYED INDIVIDUALS & BUSINESS APPLICANTS ONLY MUST ANSWER (Required - please answer all questions to prevent underwriting delays.) All Self-Employed must complete questions (Attach an explanation for all YES responses on a separate sheet of letterhead.) 1. Have you or any of your employees ever had any of the following: revoked, suspended, refused, denied renewal, placed on probation, cancelled, or voluntarily surrendered or is such an action pending? State License or Certification q YES q NO Malpractice Insurance q YES q NO 2. Has any claim or suit ever been brought against you or any of your employees or are you or any of your employees aware of any incident that might reasonably lead to a claim or suit? q YES q NO 3. Indicate type of Business: q Corporation q Partnership q Sole Proprietor q Other 4. Please describe the services you, your corporation and its employees provide: 5. Please provide a brochure and/or web address that you use in the course of your business. 6. Do you own or operate any of the following? a. Overnight bed facilities or provide any overnight care?...q YES q NO b. Staffing Agency?...q YES q NO c. Health Club/Fitness/Exercise and/or Wellness Center of Sports Endurance or Enhancement Facility?.q YES q NO d. A business other than Physical Therapy?...q YES q NO If yes, please explain: 7. Do you or any of your employees offer weight control or diet programs?...q YES q NO 8. Do you or any of your employees provide treatment or assessment in a nursing home and/or assisted living facility?...q YES q NO If yes, please explain your activities and include the total percentage of your time that you provide treatment in these facilities: 9. Do you or any of your employees administer anesthetics or radiation therapy?...q YES q NO 10. Are all professionals listed on the application certified and/or licensed for the duties they are performing?...q YES q NO If no, please explain: 11. Do you engage in any business enterprise other than physical therapy and/or medical rehabilitation?...q YES q NO If yes, please explain: 12. Do you or your business (if any) use independent contractors? (If YES, answer questions a-f.)...q YES q NO a) How many independent contractors have you used in the past 12 months? b) How many total full or partial days did you use independent contractors in the last 12 months? c) How many independent contractors do you intend to use over the next 12 months? A premium must be paid for every independent contractor identified on question 12c. d) Do you require in writing that all independent contractors carry their own professional liability?...q YES q NO e) Do you request to be added as an Additional Insured on all independent contractor s policies?...q YES q NO f) Do you always secure written proof of professional liability from all independent contractors?...q YES q NO I understand that I am not covered by this insurance for rendering or failure to render any professional services as a physician, surgeon, dentist, nurse midwife, nurse anesthetist, perfusionist, cytotechnologist, chiropractor, podiatrist, osteopath, or psychiatrist. I understand that these professional occupations are excluded from coverage. I understand that this insurance will not apply to any partner, principal or owner of a residential/overnight facility. The insurance described herein is subject to the terms, conditions and exclusions of the insurance policy. The insurance is excess when other insurance applies to a loss. HCPAPP-1000 (Ed.01/2010) 1BE SURE TO COMPLETE ALL PAGES AND SIGN LAST PAGE 4

7 In order to enhance the stability of this professional liability insurance program, coverage has been organized through a purchasing group, pursuant to legislation, known as the Federal Liability Risk Retention Act of 1986, enacted by Congress. Coverage is provided to the purchasing group by Liberty Insurance Underwriters Inc. Once the completed application has been approved and the premium has been received, you will automatically become a member of the Health Care Professions Purchasing Group Association, located and domiciled in Illinois and obtain the insurance coverage afforded through the Group Policy on an annual term. This application is subject to the underwriter s approval. Your completion of this application and premium payment does not bind coverage or obligate the insurance company to issue you insurance coverage. Coverage will become effective following the receipt of your acceptable application and premium payment. Your application cannot be processed unless it is completed in its entirety. The application is subject to the company s underwriting rules. Illinois Only - Illinois Medical Professional Liability Law PA Illinois Medical Professional Liability Law PA94-677, Senate Bill 475, requires insurers to implement a quarterly premium payment installment plan as prescribed by the Secretary of the Illinois Department of Financial and Professional Regulation (IDFPR). If you practice in the state of Illinois and your annual medical professional liability premium is above $500, please visit for information regarding installment payment options. YOU MUST SIGN AND DATE THIS APPLICATION (ALL STATES EXCEPT AR, CO, DC, FL, HI, KY, LA, ME, MD, NJ, NM, NY, OH, OK, PA, TN, VA, WA, WV): ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY lnsurance 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. ARKANSAS, LOUISIANA, AND WEST VIRGINIA 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. 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 POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY HOLDER OR CLAIMING WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FOR INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OF 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 APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURANCE COMPANY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. HAWAII APPLICANTS: FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT PRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH. 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 CONTAINING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. MAINE, TENNESSEE, VIRGINIA, AND WASHINGTON 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. HCPAPP-1000 (Ed.01/2010) 1BE SURE TO COMPLETE ALL PAGES AND SIGN LAST PAGE 5 Stock:

8 MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND 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 APPLICANTS: 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 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 MAYBE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. 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 MATERIAL FACT THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL BE ALSO SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. OHIO APPLICANTS: 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 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. PENNSYLVANIA 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 SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. Declaration and Signature - The undersigned, on behalf of all prospective insureds, after a reasonable inquiry, declares to the best of his/her knowledge and belief that the statements contained herein are true and are the basis of the acceptance of the risk or the hazard assumed by the Company under this Policy. It is further agreed by the undersigned, its Subsidiaries and their directors, officers and trustees that the Policy, if issued, is in reliance upon the truth of such representations. It is agreed that, although the signing of the Application does not commit the undersigned to purchase the insurance being applied for, the statements made in this Application shall become the basis of the Policy should one be purchased. The Company is hereby authorized to make any investigation and inquiry in connection with this Application deemed necessary. / / Signature of Applicant or Authorized Partner / Officer / Owner Title Date Name of individual signing this application (printed) Enclosed is my check for $ Effective Date Desired* Make check payable to Mercer Consumer and return your check and this application in the envelope provided. *May not be earlier than the date the administrator receives and approves this application. I authorize Mercer Consumer to charge my: VISA MasterCard PLEASE NOTE: We do not accept American Express or Discover Amount $ Credit Card Number: Expiration Date: Print name exactly as it appears on card: If paying by credit card, you may fax your application to HCPAPP-1000 (Ed.01/2010) 1BE SURE TO COMPLETE ALL PAGES AND SIGN LAST PAGE 6

9 Administrator: Mercer Consumer Proliability P.O. Box Des Moines, IA CA License #0G39709 Mark Brostowitz, Licensed Agent In CA d/b/a Mercer Health & Benefits Services LLC Underwritten by: Liberty Insurance Underwriters Inc. PLE-PT Copyright 2014 Mercer LLC. All rights reserved. HCPAPP-1000 (Ed.01/2010) 7 0 Stock:

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11 October 2010 Stock: Indiana Patient Compensation Fund Roster of Professional Staff Employed Individuals Only Client Number Client Name Professional Designation(s) Indiana License Number Self-Employed Individuals & Business Applicants (Must provide all of the following information) Client Number Client Name Business Name (Complete only if you own the business) Tax ID / EIN Number Corporation or Partnership? q YES q NO Professional Staff-Name O = Owner P = Partner OF = Officer E = Employee IC = Independent Contractor Occupation Professional Designation(s) Indiana License #

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13 LIBERTY INSURANCE UNDERWRITERS INC. (A member of Liberty Mutual Group and hereinafter the Company ) Effective Date: Policy Number: Issued To: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICYHOLDER DISCLOSURE TERRORISM INSURANCE PREMIUM NOTICE This notice contains important information about the Terrorism Risk Insurance Act and its effect on your policy. Please read it carefully. THE TERRORISM RISK INSURANCE ACT The Terrorism Risk Insurance Act, including all amendments ( TRIA or the Act ), establishes a program to spread the risk of catastrophic losses from certain acts of terrorism between insurers and the federal government. If an individual insurer s losses from a certified act of terrorism exceed a specified deductible amount, the government will reimburse the insurer for 85% of losses paid in excess of the deductible, but only if aggregate industry losses from such an act exceed $100 million. An insurer that has met its insurer deductible is not liable for any portion of losses in excess of $100 billion per year. Similarly, the federal government is not liable for any losses covered by the Act that exceed this amount. If aggregate insured losses exceed $100 billion, losses up to that amount may be pro-rated, as determined by the Secretary of the Treasury. MANDATORY OFFER OF COVERAGE FOR CERTIFIED ACTS OF TERRORISM AND DISCLOSURE OF PREMIUM TRIA requires insurers to make coverage available for any loss that occurs within the United States (or outside of the U.S. in the case of U.S. missions and certain air carriers and vessels), results from a certified act of terrorism AND that is otherwise covered under your policy. A certified act of terrorism means: [A]ny act that is certified by the Secretary [of the Treasury], in concurrence with the Secretary of State, and the Attorney General of the United States (i) to be an act of terrorism; (ii) to be a violent act or an act that is dangerous to (I) (II) (III) human life; property; or infrastructure; (iii) to have resulted in damage within the United States, or outside of the United States in the case of 1 2 TRIA-N Stock:

14 (I) an air carrier (as defined in section of title 49, United States Code) or United States flag vessel (or a vessel based principally in the United States, on which United States income tax is paid and whose insurance coverage is subject to regulation in the United States); or (II) the premises of a United States mission; and (iv) to have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. MANDATORY PREMIUM DISCLOSURE STATEMENT Your policy does not contain an exclusion for losses resulting from certified acts of terrorism. Coverage for such losses is still subject to, and may be limited by, all other terms, conditions and exclusions in your policy. The premium charge for this coverage for the policy period is $0. YOU NEED NOT DO ANYTHING FURTHER AT THIS TIME. The summary of the Act and the coverage under your policy contained in this notice is necessarily general in nature. Your policy contains specific terms, definitions, exclusions and conditions. In case of any conflict, your policy language will control the resolution of all coverage questions. Please read your policy. If you have any questions regarding this notice please contact your sales representative or agent. 2 2 TRIA-N

15 Mercer Consumer Insurance Compensation & Disclosure In this transaction, Mercer Consumer, a service of Mercer Health & Benefits Administration LLC, is acting as the exclusive insurance agent and program manager for Liberty Insurance Underwriters Inc. (Insurer) for this type of coverage, and not as your insurance broker. As the agent for Insurer, Mercer Consumer may provide these services: enrollments, ongoing servicing, billing, marketing, customer administrative and claim servicing and communications. In accordance with industry custom, we are compensated through commissions that are calculated as a percentage of the insurance premiums charged by insurers. We may also receive additional monetary and nonmonetary compensation from insurers or from other insurance intermediaries, which may be contingent upon such factors as volume, growth or retention of business. This compensation may include payment from insurers for marketing-related expenses or investments in technology. Our compensation may vary depending on the type of insurance purchased and the insurer selected. We will provide you additional information about our compensation upon your request. You may obtain this information by referring to and entering the security code o or call us at for specific details. To review the applicable Liberty policy form, you may download it at our website: Once you have been approved for coverage, you will also receive a complete packet of your policy documents.

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17 Professional Liability Insurance Program More Opportunities, More Responsibilities, More Risk The most responsible, skilled and experienced PT s can innocently become involved in malpractice claims. As patients are released for physical therapy sooner than ever before, your exposure to risk is growing all the time. Consider these real-life incidents: Allegation: Fall off therapeutic ball caused injury. Detail: PT attempted to place an ankle weight on the patient while the patient was sitting on a therapeutic ball. The patient fell off the ball, breaking an arm and suffering head injuries. Outcome: The claim was settled against the PT in the amount of $72,379. Allegation: Numbness during leg traction. Detail: The patient was being treated post-surgically following a fusion at C5-C7. During regularly scheduled treatment, the patient complained to the PT of lower back pain. While the patient was lying on his back with his legs in slight abduction, the PT applied mild traction while instructing the patient to take a few deep breaths. The patient coughed and then noted increased numbness in his leg (PT s version). The patient stated that the PT pulled on the leg with a twisting motion causing immediate and severe pain. An MRI showed a herniated disc at L5-S1. The treating physician was angry with the PT for treating the lumbar area, which was not prescribed. Outcome: The claim was settled against the PT for $41,000. Employer Provided Coverage is Limited You can t rely solely on the liability protection provided by your employer. Without your own professional liability protection, you could end up paying all attorney fees, court costs and loss of wages out of your own pocket because... l There may be gaps in your employer s policy. l A suit may be filed after you have terminated employment. l Most employer-provided coverage does not cover you for actions that take place outside the workplace or for actions performed outside of your job description or when established procedure was not followed. l With employer-provided coverage, you have to share your coverage with your co-workers, your employer and the business entity. l A consolidated defense for an employer usually represents the interest of the employer, not you. This protection is yours alone it is not shared with your co-workers and your institution. The plan includes a qualified consent to settle clause which requires your consent to settle claims. And, it protects you if someone you supervise, and for whom you are legally liable, is named in a suit. Coverage Features Your Choice of Professional Liability Coverage Limits $1,000,000 or $2,000,000 per incident, $3,000,000 or $4,000,000 annual aggregate. Provides protection whether you are employed full-time or part-time. Supplemental Liability Coverage Limits (Individuals only) $1,000,000 or $2,000,000 per occurrence, $3,000,000 or $4,000,000 annual aggregate. Covers you for bodily injury, property damage and personal injury occurrences not related to your professional duties. Defense Costs Legal fees and court costs incurred by the insurer on your behalf will be paid for covered claims, in addition to the liability limits, even if the suit is groundless, false or fraudulent, up to the limit of liability of the policy. Licensing Board Hearings Up to $5,000 per hearing/$10,000 annual aggregate for the investigation or defense of covered proceedings before most entities responsible for regulating your professional conduct (i.e. licensing board). Loss of Earnings You will receive payment for loss of earnings for your attendance at a trial, hearing or arbitration proceeding at the Company s request, subject to a maximum limit of $10,000 per incident. Reasonable expenses are included. Deposition Reimbursement The coverage provides you with expense reimbursement, up to $5,000, for legal representation for depositions related to your professional duties. This coverage applies when you are not named in a suit but are required to be deposed, i.e., as a witness to the event. This coverage does not apply to any services you provide as an expert witness. Locum Tenens The policy provides coverage when another professional temporarily assumes your duties and provides services on your behalf for a specific period of time. The locum tenens shares in your limits of coverage. (Available to self-employed individuals and groups.) Managed Care Contracts If you assume liability in a managed care contract, you will be covered for negligent acts, for which you are solely responsible. Claims Settlement The policy contains the important qualified consent to settle clause which requires your consent to settle claims. Subject to federal and state regulations and laws. 1 Stock:

18 Damage to Property of Others Coverage (Individuals only) You will receive up to $500 per policy period for damage you unintentionally inflict on the property of others during any non-business pursuit, yet related to your professional duties. Medical Payments Coverage (Individuals only) You will receive medical payments coverage for non-business pursuits if someone is injured in or around your home up to $1,500 per person/ $75,000 for all persons. Your policy pays medical expenses incurred up to 4 years after the injury occurs. Worldwide Protection You are covered anywhere in the world, as long as the claim is made or suit is brought in the U.S., its territories or possessions or Canada. First Aid Reimbursement The policy will reimburse you up to a maximum of $2,500 for all medical supplies you purchase and use in order to render first aid to another as covered by the certificate. Assault Coverage The policy pays up to $5,000 per assault/ $10,000 annual aggregate for medical expenses resulting from bodily injury to you or damage to your personal property if you are assaulted at work. You are also covered when traveling to and from the workplace. Self-employed Individuals & Group Practices Products Hazard Coverage for equipment specifically designed, made or altered by you for a patient or client. Separate Annual aggregates Each professional member of an insured group will have a separate annual aggregate limit. Coverage for Volunteers and Employees. Optional Coverages: General Liability Coverage Includes bodily injury and property damage associated with your business, but not your professional services, personal injury and advertising injury liability for your own business or practice and fire legal liability. Additional Insured Coverage Protects a healthcare facility you provide services to against claims arising out of the sole negligence of the persons insured. You should only purchase this if the facility requires you to. Entity Coverage Separate limits of coverage equal to those selected for the professional members are available for the entity, up to $1,000,000/ $3,000,000, for an additional premium. This feature provides the entity with a separate set of limits. Protection You Can Count On, Now and in the Future Because our program uses an occurrence form, you are covered for professional services performed during the term of the insurance certificate... no matter when the suit or claim is made. So, you have this protection now and in the future for any claims resulting from covered services you performed while the insurance certificate was in force. The Company M Consumer has been a leader in providing insurance protection to health care professionals since The M Consumer Professional Liability Insurance Program is endorsed by over 200 professional state and national organizations. M Consumer and the Liberty Insurance Underwriters Inc. have worked closely together to develop one of the most competitive programs available for Physical Therapists. As the administrator of this program, M Consumer is dedicated to providing you with the customer service you deserve. Administered by: Mercer Consumer Proliability P.O. Box Des Moines, IA CA License #0G39709 Mark Brostowitz, Licensed Agent In CA d/b/a Mercer Health & Benefits Insurance Services LLC Underwritten by: Liberty Insurance Underwriters Inc. This brochure contains a summary of the insurance certificate provisions. If there is a conflict between this brochure and the actual insurance certificate, the insurance certificate language will control. Restrictions This program is designed to provide professional liability insurance protection. You are not covered while operating a motor-driven vehicle, when engaged in any other business outside your professional duties, when engaged in an unlawful action, or when acting as a proprietor, owner, partner, manager, superintendent, or officer of any hospital, sanitarium, medical clinic, health maintenance organization, managed care facility, foster care agency, adoption agency or any other facility not specified in the Declarations. You are not covered when acting as a physician, surgeon, dentist, nurse midwife, chiropractor, podiatrist, osteopath, psychiatrist, cytotechnologist, or perfusionist or any other medical specialist not named in the Declarations. See insurance certificate for complete list of exclusions. Copyright 2014 Mercer LLC. All rights reserved. PLP-PT 2