APPLICATION FOR MISCELLANEOUS MEDICAL PROFESSIONAL LIABILITY INSURANCE
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1 APPLICATION FOR MISCELLANEOUS MEDICAL PROFESSIONAL LIABILITY INSURANCE Sectin I General Infrmatin 1. Full Name f Applicant: 2. Mailing and Lcatin Address: (Include all dba s and subsidiaries seeking cverage under the plicy fr which yu are applying.) (If multiple addresses include an attachment with a cmplete schedule f all lcatins) 3. Website Address (if applicable): 4. Date Established: 5. Type f Entity: Fr Prfit n Prfit Gvernmental Entity Partnership Sle Partnership Prfessinal Assciatin Crpratin Franchise Other (Describe): 6. Is this entity wned by, assciated with r cntrlled by any ther entity? If, please explain: 7. Descriptin f Operatins: 8. Are any f yur services prvided in, r under cntract with a facility r entity that yu wn, perate r are smehw affiliated with? If, please explain: 9. Des the applicant wn, perate r manage any business ther than the ne(s) described in this applicatin fr which yu are applying fr cverage? If, please prvide cmplete details, including name f entity, yur wnership interest r cntractual relatinship and infrmatin n their insurance prgram. 141APP1016 Page 1 f 8
2 10. Within the next 12 mnth perid, des the applicant plan t: a. Obtain anther peratin r entity? b. Add t the number f emplyees? c. Expand the number f lcatins? d. Eliminate/Add current services? e. Operate in ther states? If yes t any f these uestins please explain: 11. Organizatin Accreditatins/Certificatins/Licensures a. Accredited: b. Certified: c. Licensed: d. Has the applicant s accreditatin certificatin r license been suspended r revked? If yes, please explain: Sectin II Expsures PROFESSIONAL ACTIVITIES AND SPECIALTY: 12. Describe in detail yur prfessinal services and indicate the percentage f grss receipts/revenue derived frm each activity. 13. Please cmplete all sectins that apply. Revenue # f Outpatient Visits # f Inpatient Beds # f n- Emergency Transprts # f Emergency Transprts # f Students Next 12 Mnths Last 12 Mnths Tw years ag 141APP1016 Page 2 f 8
3 medical malpractice cverage fr their services n behalf f this enity: Emplyee r Vlunteer Independent Cntractrs Insured n Own Med Mal Plicy Current PL Limits Physicians (n surgery)* Physicians (surgical)* Physician Assistants Surgical Technicians Certified Nurse Anesthetists Nurse Practitiners Registered Nurses LPN s r Nurse Aides X-Ray Technicians Medical Assistants Optmetrists Opticians Pharmacists Pharmacy Technicians Chirpractrs Massage Therapists Labratry Technicians Paramedics EMT s Scial Wrkers Aestheticians Other: *Please attach cpies f declaratins pages n all individuals that carry their wn medical malpractice. 15. Are all f the abve individuals licensed in accrdance with applicable state and federal regulatins? If n, prvide detailed explanatin. 16. Medical Directr/Physician/Surgen. Prvide infrmatin fr the Medical Directr and each physician/surgen prviding services at applicant s facility: Medical Directr s Name Specialty Bard Certified (Y/N) Insurance Carrier State f Licensure License Number Emplyee/Ind Cntractr Hurs per Mnth 17. D yu need t include cverage fr yur Medical Directr s direct patient care? If s, please describe the services being prvided. 141APP1016 Page 3 f 8
4 141APP1016 Page 4 f 8
5 Sectin III Risk Management 24. Are yu accredited by any accrediting rganizatins? If, please explain: 25. Please list the assciatin in which yu are a member: 26. Please explain yur Quality Assurance and Risk management Prgram: 27. Are backgrund checks perfrmed fr all emplyees, independent cntractrs and vlunteers? If, what level r type f the criminal backgrund checks: Cunty State Federal Sexual Offender Registry If, please explain: 28. Are all emplyees, independent cntractrs and vlunteers screened fr drugs and alchl? If yes, hw ften are screens perfrmed? 29. Hw are patients referred t yur firm? 30. D yu have back-up prcedures if assigned staff is nt able t make a scheduled visit? 31. D yu require any f yur independent cntractrs t carry prfessinal liability? If, please prvide details. 32. D yu have a plicy in place t prevent sexual abuse r allegatins f sexual abuse? If, please explain and advise hw ften it is reviewed. 33. Have any emplyee(s) been the subject(s) f alleged r actual incidents regarding abuse/mlestatin r child abuse/neglect? If, prvide details n a separate attachment. Sectin IV Netwrk Security Measures and Prcedures 34. Please describe security measures and prcedures used t prtect sensitive data and mbile hardware (laptps, cmmunicatin devices, etc) in yur care, custdy, and cntrl. 141APP1016 Page 5 f 8
6 35. Please describe security measures and prcedures used t prtect, mnitr, and track mbile hardware (laptps, 36. D yu have a frmal dcumented security plicy? Are all emplyees required t read, receive, and understand security plicy? 37. Are yu currently HIPAA/HITECH cmpliant? 38. D yu u ncryp n fr data stred? D yu u ncryp n fr data transm d between lca ns r systems? 39. D yu backup cmputer systems and data? a. backups perfrmed? b. If yes: Are backups stred ff site? 40. Are yur cmputer systems and netwrks a vely mnitred? If yes: By whm? 41. Have yu experienced any security breaches r data lss events? If yes: Please explain Sec n V Current Cverage 42. Please prvide the fllwing infrma n as respects the last five years f PROFESSIONAL LIABILITY cverage beginning with the mst current cverage: (If nne, state NONE.) Carrier Limit Dedu ble Premium Plicy Term Retr Date 43. Is the applicant currently insured under a Cmmercial GENERAL LIABILITY plicy? Carrier Limit Deductible Premium Plicy Term Retr Date 141APP1016 Page 6 f 8
7 Sectin VI Claims 44. Has any applicatin fr prfessinal liability insurance made n behalf f the applicant, any predecessrs in business r present partners ever been declined, cancelled r nn-renewed? If, please prvide details including name f carrier and date: 45. Has any claim ever been made against the applicant r any f its emplyees? If, please cmplete the Supplemental Claim Infrmatin Frm fr each and every claim. Frm Link Please fax t r t chris@phyadv.cm The Physicians Advcate an Acrisure Agency Partner 2335 E. Atlantic Blvd., Suite 302 Pmpan Beach, Fl Phne: Cell: APP1016 Page 7 f 8
8 The applicant declares that the abve statements and representatins are true and crrect and that n facts have been suppressed r misstated. The cmpletin f this applicatin des bind the Cmpany t sell nr the applicant t purchase this insurance, but any subsequent cntract issued will be in full reliance upn the statement and representatins made in this applicatin and this applicatin will be made a pert f the plicy. The applicant understands that any subsequent cntract issued by the Cmpany will be issued n a claims made frm. Electrnic Signature f Applicant f Authrized Representative: Current Date: Title If yu prefer nt t return Applicatin with an electrnic signature, please print and sign belw. Signature f Applicant f Authrized Representative Current Date: Title ADDITIONAL INFORMATION - Please prvide the fllwing infrmatin with this applicatin: a. Advertisements, brchures, descriptive literature b. Sample cntract between yu and the clinical trial investigatr, if the investigatr is nt yur emplyee r enplyee f the test site facility. c. Infrmed cnsent dcument Please prvide any additinal details in the space prvided: 141APP1016 Page 8 f 8
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