Physical Therapists and Related Occupatins Applicatin Darwin Natinal Assurance Cmpany Main Administrative Office: Crprate Office: 9 Farm Springs Rad 1807 Nrth Market Street Farmingtn, CT 06070 Wilmingtn, DE 19802 Offered thrugh the Prfessinal Cunselrs Purchasing Grup, Inc. NOTICE: THIS IS AN APPLICATION FOR PROFESSIONAL AND PREMISES LIABILITY INSURANCE. SUBJECT TO ITS TERMS, THIS POLICY PROVIDES COVERAGE FOR CLAIMS ARISING FROM WRONGFUL ACTS OR OCCURRENCES THAT TAKE PLACE DURING THE POLICY PERIOD. DEFENSE EXPENSES PAYABLE UNDER THE POLICY ARE PAYABLE IN ADDITION TO THE LIMITS OF LIABILITY. A SMALLER LIMIT OF LIABILITY WILL APPLY TO JUDGMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS OF SEXUAL MISCONDUCT, OR TO ANY SUPPLEMENTAL PAYMENT. If a plicy is issued, the applicatin will becme part f the plicy as if physically attached. Therefre, it is necessary that all questins be answered accurately and cmpletely. Are Yu: Attach a separate sheet f paper if mre space is needed t answer any questin. Attach cpy f current state license r certificatin Attach prmtinal materials used in yur practice Attach any claims histry fr prfessinal r premises liability Self-Emplyed (Self-Emplyed means an individual wrking fr themselves r with thers as partners r as wners f a grup r entity.) Emplyee (Emplyee means a persn wh has been hired t perfrm services, and wh has an assigned wrk schedule and appears n a payrll with applicable federal, state and lcal taxes withheld, e.g. W-2.) Student (1) General Infrmatin (a) Applicant s Name: (b) Address: City: State: ZIP: (c) E-mail address: Telephne number (d) License/Certificatin # (if applicable) (e) If Yu answered Self-Emplyed, please prvide the fllwing additinal infrmatin: (i) Are Yu a: PC Sle Prprietr/Individual Partnership LLP LLC Crpratin Jint Venture Other If Other, please describe: Name f Entity if different than Name f Applicant: Key Cntact Name: Title: (ii) Are Yu seeking Premises Liability cverage? DRWN c1010-pt-nj (9/2009) Page 1 f 5
(iii) Are Yu required by cntract t include an individual r entity as an additinal insured under the plicy fr prfessinal services yu r any f yur emplyees prvide? (Additinal Insured cverage prtects a third party Yu prvide services fr against claims arising ut f wrngful acts. Yu shuld nly purchase this cverage if yu are required t.) (iv) Are Yu seeking cverage fr any subsidiary? Please nte that cverage fr such subsidiaries is nt autmatically available; the terms and cnditins f the plicy, if issued, will determined actual cverage. Name/Address Relatin t applicants Descriptin f Ops Tax Status Percent Owned (f) If Yu answered Emplyee, please prvide the fllwing additinal infrmatin: Emplyer Name: Emplyer City, State: (2) Requested Effective Date: (3) Descriptin f Practice (a) Eligible Occupatins - Please check all Specialties perfrmed in Yur practice: a. Athletic Trainer b. Bdywrk Cunselr c. Chirpractic Assistant d. Crrective Therapist e. Exercise Physilgist f. Fitness Instructr g. Kinesilgist h. Kinesitherapist i. Massage Therapist j. Occupatinal Therapist k. Occupatinal Therapist Assistant l. Orthpedic Assistant m. Orthpedic Technician n. Pedrthist. Persnal Trainer p. Physical Therapist q. Physical Therapist Aide r. Physical Therapist Assistant s. Physitherapist t. Recreatinal Therapist u. Rehabilitatin Assistant v. Rehabilitatin Cunselr w. Rehabilitatin Technician x. Rehabilitatin Therapist y. Sprts Medicine Instructr z. Sprts Medicine Therapist DRWN c1010-pt-nj (9/2009) Page 2 f 5
(b) List Yur name and qualificatins. In additin, list the names and qualificatins f each individual wh perfrms services fr Yu r n Yur behalf, except clerical services. If additinal space is required, please use a separate sheet f paper. Name Degree Degree Title Field Of Study Specialty/ Specialties (List all specialties perfrmed) Number f hurs f practice each week License r Certificatin State Title Number Expiratin Date Emplyment Status (Indicate Partner r Owner, Emplyee (W-2), Independent Cntractr (Frm 1099), r Student.) NOTE: Independent Cntractrs (Frm 1099) are nt cvered under this Plicy, unless specifically included by Endrsement. Yu will, hwever, be cvered fr their acts, subject t the terms and cnditins f the Plicy. If Yu have listed Independent Cntractrs abve, mre infrmatin may be requested frm the Insurer, as well as additinal premium, t include them in the cverage available under the Plicy. (4) D Yu and Yur emplyees, r independent cntractrs, have a degree, certificatin r training frm an accredited institutin, assciatin, licensing bard, r regulatry agency respnsible fr maintaining the standards f the speciality/specialties selected? (5) D Yu r any f Yur emplyees r independent cntractrs practice any f the specialties selected at any jail, prisn, crrectinal facility r any similar type f facility? (6) Suits, Claims r Ptential Claims (a) Has any claim r lawsuit fr malpractice ever been brught against Yu r any f Yur emplyees r independent cntractrs? (b) Have Yu r any f Yur emplyees r independent cntractrs ever been the subject f cmplaints, charges, r disciplinary actin against Yu fr any reasn, by a curt, licensing bard r regulatry agency respnsible fr maintaining the standards f Yur prfessin? DRWN c1010-pt-nj (9/2009) Page 3 f 5
(c) Have Yu r any f yur emplyees r independent cntractrs ever engaged in any sexual miscnduct with any f Yur current r frmer patients, r any current r frmer patient s spuse, r any persn with a direct relatinship t a current r frmer patient r any current r frmer patient s spuse r any persn with a direct relatinship t the patient r frmer patient (fr example, a guardian, bld relative f the patient r spuse r any persn sharing the patient s dmicile)? (Sexual miscnduct means any actual r alleged ertic physical cntact r attempt, threat r prpsal theref whether cnsensual r nt.) If Yu answered Yes t the questins (6)(a), (6)(b) r (6)(c) abve, prvide cmplete details n a separate page and attach it t the applicatin. MISSOURI APPLICANTS DO NOT ANSWER QUESTION (7). (7) During the past five years, has Yur Prfessinal Liability cverage been cancelled r nn-renewed fr a reasn ther than the insurer withdrawing frm a state r n lnger prviding cverage? If Yu answered Yes t the questin abve, prvide cmplete details n a separate page and attach it t the applicatin. SIGNATURES, NOTICES AND REPRESENTATIONS THE UNDERSIGNED AUTHORIZED REPRESENTATIVE, PARTNER, DIRECTOR OR OFFICER AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE THE APPLICATION IS EXECUTED AND THE TIME THE PROPOSED INSURANCE POLICY IS BOUND OR COVERAGE COMMENCES, THE NAMED INSURED WILL IMMEDIATELY NOTIFY THE INSURER IN WRITING OF SUCH CHANGES. THE INSURER RESERVES ITS RIGHTS TO MODIFY OR WITHDRAW ITS PROPOSAL. THE UNDERSIGNED AUTHORIZED REPRESENTATIVE, REPRESENTS AND WARRANTS ON BEHALF OF THE NAMED INSURED AND ALL PERSONS OR ENTITIES FOR WHOM INSURANCE IS BEING SOUGHT THAT TO THE BEST OF HIS OR HER KNOWLEDGE AND BELIEF AND AFTER DILIGENT INQUIRY, THE STATEMENTS SET FORTH IN THIS APPLICATION AND ANY ATTACHMENTS HERETO ARE TRUE AND ACCURATE. IT IS UNDERSTOOD THAT THE STATEMENTS IN THIS APPLICATION, INCLUDING MATERIALS SUBMITTED TO OR OBTAINED BY THE INSURER, ARE MATERIAL TO THE ACCEPTANCE OF THE RISK, AND RELIED UPON BY THE INSURER. NOTICE TO APPLICANTS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY, 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 ACT, WHICH IS A CRIME ANY MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. 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. DRWN c1010-pt-nj (9/2009) Page 4 f 5
I UNDERSTAND THAT IT IS MY OBLIGATION TO MAINTAIN ANY LICENSE REQUIRED IN THE JURISDICTION(S) IN WHICH I PRACTICE. Date: Title: Signature: Print Name: Signature f Authrized Representative f the American Prfessinal Agency, Inc.: Please make checks payable and mail t: American Prfessinal Agency, Inc. Prgram Administratr: AMERICAN PROFESSIONAL AGENCY, INC. 95 Bradway, Amityville, NY 11701 (631) 691-6400 (800) 421-6694 www.americanprfessinal.cm DRWN c1010-pt-nj (9/2009) Page 5 f 5
IMPORTANT INFORMATION PURCHASING GROUP FEE NOTICE A $5.00 annual Purchasing Grup fee needs t be added t yur premium t help defer the administrative csts fr maintaining the Prfessinal Cunselrs Purchasing Grup. CORPORATE COVERAGE Please nte that if yu are applying fr crprate cverage, the fllwing must be included when sending in yur applicatin: a letter describing all services prvided, include any brchures if available, as well as a cpy f yur articles f incrpratin, and a listing f wners and/r partners indicating the percentage wned by each. Premise Liability Cverage If yu answer YES t Are yu seeking Premises Liability Cverage?, please indicate the limit yu chse. Nte that this cverage is nly available fr selectin by accunts with Self Emplyed individuals. The per claim limit fr the Premises Liability Cverage must be less than r equal t the per claim limit fr the Prfessinal Liability Cverage. Check Yur Selectin Limit Charge $100,000/$300,000 $75 $500,000/$1,000,000 $85 $1,000,000/$3,000,000 $100 Please make check payable and mail t: American Prfessinal Agency, Inc. 95 Bradway Amityville, NY 11701 Special Nte: If paying by credit card r Vcheck* (virtual check), please indicate the methd n the applicatin. * Vcheck is a methd where yu enter yur check infrmatin in an easy-t-use secure nline frm. This infrmatin is used t generate a ne-time check that we take t the bank. Yu tell the system yur ruting and accunt number, payee, check number and dllar amunt (Infrmatin that is already n yur check). Click Here! Fr yur FREE, first-time listing in Psychlgy Tday s Therapy Directry. Start getting clients - A $180 value frm APA, Inc.