Has the insured, in the last 10 years in business ever been without professional and/or general liability Insurance? 0 Yes 0 No

Transcription

1 Applicant Information Applicant Name: Mailing Address Location Address (If Different): County (ies) doing business in: Telephone Number: Corporate Structure: 0 Individual 0 Corporation 0 LLC 0 Other: 0 Not For Profit Applicant Type: 0 Sole Proprietorship 0 Partnership 0 Corporation 0 Limited Liability Coverage Information Proposed Effective Date: Retroactive Date: Requested Limits of Liability: Requested Deductible: Other Coverages: 0 Defense Outside Limits 0 Punitive Damages 0 Physical & Sexual Abuse Compounding Gross Receipts Next 12 Months: History (Explain any Yes answers on a separate sheet) Has the insured, in the last 10 years in business ever been without professional and/or general liability Insurance? 0 Yes 0 No Have any claims been made or occurrences reported during the past ten years against any of the proposed insureds or against any entity in which any proposed insured has or has had an interest? 0 Yes 0 No Does any proposed insured have any knowledge of an event, circumstance, or occurrence prior to the effective date of the proposed policy, or does any proposed insured foresee that a claim may be brought as a result of said event, circumstance, or occurrence? 0 Yes 0 No Has the applicant or any employee ever had any professional license refused, suspended, revoked, renewal refused or accepted only with special terms, or has the applicant or any of their employees voluntarily surrendered any professional license? 0 Yes 0 No Has the applicant or any employee ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses? 0 Yes 0 No Page 1 of 6

2 Prior Insurers (List prior insurers for the past five years, starting with the most recent year. If none, so state.) Insurer Policy Number Limits of Liability Premium Eff. Date Claims Made Exposures Service is licensed as: Describe the nature of the operation, including types of services rendered and activities conducted: List all memberships in professional organizations: Total number of all staff: Number of Professional Staff: Employed Contracted Employed Contracted Aides or Orderlies Acupuncturists Audiologists Chiropractors Dentists Dental Hygienists/ Tech. Dental Assistants Dietitians/ Nutritionists EEG or EKG Operators Optometrists Opticians Paramedics or EMT s Pharmacists Pharmacy Technicians Physicians or Surgeons* Physician Assistants Physiotherapists/ Physical Therapists Podiatrists Page 2 of 6

3 Employed Contracted Employed Contracted Electrologists Hearing Aid Fitters Inhalation/Resp. Therapy Laboratory Techs LPN s Massage Therapists Medical Techs Nurse Midwives Nurse Practitioners Prosthetic Device Fitters Psychologists/ Psychotherapists RN s Social Workers Speech Therapists Veterinarians X-Ray or Radiologist Techs X-Ray or Radiologist Therapists Occupational Therapists Other (describe): * - Attach list and indicate specialty If you contract for services of any outside health care staff, breakdown total estimated annual payments to contractors and annual estimated Outpatient Visits by professional category. Do you require contracted staff (if any) to carry their own Insurance and secure Certificates of Insurance as evidence of such coverage? Do you require employed or contracted physicians, surgeons, nurse anesthetists, dentists, podiatrists, or chiropractors to carry their own Insurance and secure Certificates of Insurance as evidence of such coverage? Does the applicant desire to provide coverage for independent contractor(s) including them as additional insured(s) on their policy while working on the applicant s behalf? 0 Yes 0 No What minimum limits of are required? What was your total number of patient/client visits last year? Estimated visits next year? Does the applicant offer Adult Day Care services? 0 Yes 0 No If yes, please provide average occupancy: Page 3 of 6

4 Breakdown of patient services % Service % Service Pediatric Dental Obstetric Psychiatric Rehabilitative Therapy Minor Surgery Major Surgery Gynecological Emergency Medical General Exams Occupational Medical Optometry/Ophthalmology Nutrition (Diet) Orthopedic Other (describe): Are any of the following performed? Administration of anesthesia (general or local): 0 Yes 0 No Surgery (major or minor, including Face Peel, Dermabrasion, Silicone Injection, and Needle Biopsies): 0 Yes 0 No Cardiac Catheterization: 0 Yes 0 No Diagnostic tests: 0 Yes 0 No Chemotherapy: 0 Yes 0 No X-Rays: 0 Yes 0 No Radiation Therapy: 0 Yes 0 No Reduction of Fractures: 0 Yes 0 No Shock Therapy: 0 Yes 0 No Prescribe Medication: 0 Yes 0 No Obstetric Procedures: 0 Yes 0 No For all yes answers, please give a detailed description on a separate sheet. Risk Management Name of Administrator/Supervisor and describe his/her training and experience. Do you enter into contractual agreements? 0 Yes 0 No If yes, please enclose copies of all such contracts. Do you require staff to report all incidents which might result in a liability claim, and are records of such reports kept on file by you? 0 Yes 0 No If not, are you agreeable to instituting this procedure? 0 Yes 0 No Enclose a copy of all brochures or advertising materials distributed by you Page 4 of 6

5 Describe any fundraising or other special events activities conducted. Describe any swimming pool, playground, or amusement exposure. Do you rent, sell, or otherwise provide any equipment or products to others? 0 Yes 0 No If yes, please complete our Products Supplement. Do you provide 24 hour bed and board care for any patients, or do you (wholly or in part) own, operate, or administer any facility which does provide such services? 0 Yes 0 No If yes, please complete our Residential Facilities Application. Do you provide any of the following services? Blood Bank/Plasma Centers 0 Yes 0 No Cemeteries/Funeral Homes/Morticians 0 Yes 0 No Medical Arts Schools and Colleges 0 Yes 0 No Pharmacies 0 Yes 0 No Nursing Homes 0 Yes 0 No If yes, please complete the appropriate supplement application. Do you have any other premises or operations exposures not stated in this application? 0 Yes 0 No If yes, please enclose complete description and underwriting/rating information. Other Information I understand and agree that this Application and any and all supplements attached hereto may be made a part of any policy issued, and any such insurance will be issued by relying upon the representation made herein. I further understand and agree that failure to provide a true and accurate response to the foregoing questions may, at the option of the Company, result in the voiding of insurance issued in reliance on this Application and/or denial of claims under any policy issued. I authorize and consent to investigations or release of documents containing information relative to moral character, professional reputation, and fitness to engage business. I authorize the release of any information public or private to Greenhill Insurance related to this purpose. I understand and agree that these investigations shall not be confined to information submitted in this application, but shall include any other sources of information deemed relevant by the Company as may be authorized by law. Applicant and all owners, employees, and contractors are licensed or duly authorized in all states or jurisdictions where professional services are provided. Applicant warrants the truth of all answers to the above questions, and that applicant has not withheld any information which is calculated to influence the judgment of the insurance company in considering this application. I confirm that I am authorized to sign this application on behalf of the applicant. Important: This application must be signed by the applicant. Signing this form does NOT bind Greenhill or the company to complete the insurance. Signed Date Title Page 5 of 6

6 Agency/Broker Information Agency Name: Broker/Contact Name: Telephone: Page 6 of 6