Maryland-1-2018-Renewal-VL Renewal Application Including Vicarious Liability Application - if applicable. Please type your responses directly on the application, sign and submit via: Email: Renewal@prms.com Fax: (703) 276-9530 Mail: PRMS Attn: Renewal 1401 Wilson Boulevard, Suite 700 Arlington, VA 22209 If you have any questions, please feel free to contact us at (800) 245-3333 or ClientServices@prms.com. Thank you! Please complete and include this cover sheet with your application submission. First Name: Last Name: Practice State:
Medical Professional Liability Insurance Application Individual Psychiatrist - Maryland Applicant Name: Date of Birth: First, Middle, Last and Title (MD or DO) Month, Day and Year Mailing Address: Phone: City: State: Zip: Mobile: Website: Email: Authorized Contact and Email (if other than applicant): List active license number and state List any psychiatric association membership(s) I: Coverage Requested: 1. Effective date of coverage: 2. Limits of liability: $200,000/$600,000 $500,000/$1,500,000 $1,000,000/$3,000,000 $1,300,000/$3,900,000 Other: 3. Deductible Option: NONE $25,000 $50,000 $100,000 4. Coverage type: Occurrence Claims Made - Retroactive date: If prior coverage was on a claims-made policy, was the Extended Reporting Period Endorsement (tail coverage) purchased? N/A N/A If no, please explain: N/A Are you requesting prior acts coverage? N/A N/A If no, please explain: N/A 5. Practice specialty: General psychiatry % Child and adolescent psychiatry % Addiction psychiatry % Pain management % Geriatric psychiatry % Forensic psychiatry % Other (please specify: % 6. Average number of hours per week requested for this policy: If 20 hours or less, will you be performing any activities which will be covered by another professional liability policy? 7. Are you currently a resident or fellow, or did you successfully complete a psychiatric residency or fellowship? List Specialty: Currently in training: Completion Date: MM/YYYY Year of practice following completion of residency or fellowship at time of this application: First year in practice Second year in practice Third year in practice More than three years in practice PRMS, Inc. In California, d/b/a Transatlantic Professional Risk Management and Insurance Services, Inc. FA-PY-402-A-MD 01-2018 Page 1 of 6
8. Have you completed four or more CME hours specific to risk management in the past year? If your practice is primarily located in New York, were the risk management hours specific to the New York Excess Seminar? II: Practice Location 1. Provide location where our coverage is requested: (if multiple locations, please provide information for each additional practice location on page 6). Practice Name: County: Practice Address: City: State: Zip: Is the majority of your weekly practice time at this location? If the practice is incorporated and you are the sole owner of the practice, the entity will be included as an insured and share your policy limits of liability (may vary by state). Do you employ/contract other professional healthcare providers?. If yes, please complete an entity application and include a copy of your articles of incorporation and current certificate(s) of insurance for all professional healthcare provider co-owners, employees or independent contractors. 2. Indicate percentage of total practice time for each location and be sure to complete the practice location information for each if insurance is requested for this policy: Private Office % Home Office % Community Health Center % Detention Facility % Treatment Center % Home Health % Nursing Home % Inpatient Facility % Government Facility % Outpatient Clinic % Residential Facility % Other: % 3. List any practice locations covered by other insurers, employers or self-insured programs: Practice Name: III. Additional Information: 1. Have you practiced without continuous medical professional liability insurance coverage? If yes, please explain the period of time and reason for the gap in coverage. If you were insured by an employer, you may answer No. If yes, please explain: 2. Has your professional liability insurance coverage ever been cancelled, refused renewal, denied or accepted subject to any conditions or restrictions? - If yes, please explain: Note: Missouri applicants do not respond. 3. Are records created and maintained for each patient, and do you document informed consent? PRMS, Inc. In California, d/b/a Transatlantic Professional Risk Management and Insurance Services, Inc. FA-PY-402-A-MD 01-2018 Page 2 of 6
4. Do you engage in these practices for which this policy is requested (check all that apply and indicate percentage of practice time for each)? Medication management % If yes, do you provide proper monitoring for medication levels, physiological reactions and drug interactions? If no, please explain: If yes, do you conduct an initial patient clinical evaluation before prescribing medications? If no, please explain on page 6: Telepsychiatry % If yes, are you licensed in the state where the patient is located? Please indicate the county and state where the majority of your telepsychiatry patients are located: County State Unconventional therapy % Please explain on page 6. Clinical trials or research % Collaborative agreement % Treatment by email % 5. If any of the following are answered Yes, please provide pertinent documents with explanations. a. Has any lawsuit, claim, investigation or civil proceeding regarding your psychiatric practice been brought against you in the past 10 years (or at any time if involving sexual misconduct)? Or are you aware of any incidents that might reasonably result in a claim, investigation or civil proceeding? If yes, please explain and provide a claims history report from your insurer(s) over the past 10 years. b. Are you aware of any occurrences, accidents, conduct, circumstances, complications or unexpected outcomes for psychiatric services that might reasonably be expected to result in a claim, lawsuit, investigation, or civil investigation or proceeding known to you or which should have been known to you on the date of this application? c. Have any of your professional licenses, certificates or hospital privileges or applications for these been declined, subject to an investigation or proceeding for any reason, or have they been voluntarily surrendered or nonrenewed in lieu of disciplinary action in the past 10 years? d. Have you ever been or are you currently sexually, romantically, socially or professionally (e.g., a business venture) involved with any current or former patient, or with a key third party of a patient? e. Have you ever been convicted of, plead guilty to, or plead no contest to a felony or other criminal proceeding? f. Have you ever experienced any dependency upon or been treated for abuse of alcohol, narcotics or other drugs? g. Have you ever been diagnosed with any physical or mental condition that impairs or could impair your ability to practice medicine? h. Have you ever been denied a specialty board certification or re-certification? PRMS, Inc. In California, d/b/a Transatlantic Professional Risk Management and Insurance Services, Inc. FA-PY-402-A-MD 01-2018 Page 3 of 6
If you are a Kansas resident, you must complete the Kansas Health Care Providers Only supplemental application in addition to this application. All Applicants: Please read the following declarations carefully. All questionnaires must be signed and dated. 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 with Fair American Insurance and Reinsurance Company. 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. NOTICE TO 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 ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO ARKANSAS, NEW MEXICO 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. 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 POLICYHOLDER 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 DEFRAUDING THE INSURER OR 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. 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. PRMS, Inc. In California, d/b/a Transatlantic Professional Risk Management and Insurance Services, Inc. FA-PY-402-A-MD 01-2018 Page 4 of 6
NOTICE TO ILLINOIS APPLICANTS: THE DISCOVERY OF ANY FRAUD, INTENTIONAL CONCEALMENT, OR MISREPRESENTATION OF MATERIAL FACT IN THE POLICY WILL RENDER THIS POLICY, IF ISSUED, VOID AT INCEPTION. THE DISCOVERY OF ANY FRAUD, INTENTIONAL CONCEALMENT, OR MISREPRESENTATION OF A MATERIAL FACT DURING A CLAIM WILL RENDER THIS POLICY, IF ISSUED, CANCELLED. 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 THERETO, 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 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 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 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. NOTICE TO MINNESOTA APPLICANTS: A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. 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 APPLICATION 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 (365:15-1-10, 36 3613.1). NOTICE TO OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR PRMS, Inc. In California, d/b/a Transatlantic Professional Risk Management and Insurance Services, Inc. FA-PY-402-A-MD 01-2018 Page 5 of 6
STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, MAY BE GUILTY OF A FRAUDULENT ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO 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. NOTICE TO 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 INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. NOTICE TO VERMONT 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 ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. THE APPLICANT AGREES IF THE INSURANCE COVERAGE APPLIED FOR IS WRITTEN, THAT THIS APPLICATION AND ANY ATTACHMENTS ARE DEEMED ATTACHED TO AND INCORPORATED INTO THE POLICY. BY TYPING MY NAME IN THE FIELD BELOW, I AGREE IT IS EQUIVALENT TO MY SIGNATURE ON THIS DOCUMENT AND I CONSENT TO CONDUCT THE TRANSACTION TO WHICH THIS DOCUMENT IS APPLICABLE BY ELECTRONIC MEANS. Applicant s Personal Signature Date Further explanation if needed: PRMS, Inc. In California, d/b/a Transatlantic Professional Risk Management and Insurance Services, Inc. FA-PY-402-A-MD 01-2018 Page 6 of 6
Renewal Application Vicarious Liability Is your practice structure any of the following: Employer of other Professionals Contractor of the services of other professionals Professional Corporation with more than one shareholder Incorporated Solo Private Practice (e.g., "MD, Inc.") Professional Partnership/ Association Fictitious Name Entity or DBA Joint Venture or LLC If yes, please complete and submit the following Vicarious Liability application. If yes, please complete and submit the following Vicarious Liability application. Additionally, if your business has healthcare providers who are co-owners, employees or independent contractors, please include a copy of their current malpractice insurance (e.g. Certificate of Insurance, COI) if they are not a PRMS active client. What is Vicarious Liability? Vicarious liability coverage provides insurance for you and your practice entity for the liability you assume for the actions of others you are legally responsible for. It protects you for legal proceedings based on the business relationship with your co-owners, employees and independent contractors who are healthcare providers. For example, you or your entity may be sued for the professional services provided by an employed psychiatrist, social worker, or other healthcare professional based solely on your employment relationship.
FAIR AMERICAN INSURANCE AND REINSURANCE COMPANY PSYCHIATRISTS' PROFESSIONAL LIABILITY INSURANCE PROGRAM PRACTICE STRUCTURE/VICARIOUS LIABILITY COVERAGE IMPORTANT: A copy of the articles of incorporation must accompany the application. A copy of all written agreements which establish the identity of the partnership must accompany the application. Prior to answering any questions referring to any employees, independent contractors, partners, or shareholders, please inquire of each of these individuals as to whether they have information pertinent to the question. (Please print or type all requested information.) Full Name: 1. Practice Structure: Employer of other Professionals Contractor of the services of other professionals 2. Limit of Liability requested: Shared Limit of Liability with the Named Insured Note: Shared limits not available for: IN, KS, LA, PA, WI Customer ID Number: Professional Corporation with more than one shareholder Incorporated Solo Private Practice Professional Partnership/Association Fictitious Name Entity or DBA Joint Venture or LLC Separate Limit of Liability from the Named Insured 3. Name of the Professional Corporation, Partnership, Practitioner with Employees/Independent Contractor Professionals, Fictitious Name Entity or DBA: (Note: Coverage is not available to business corporations.) 4. Practice Address (Not previously listed. Please attach a separate sheet for additional locations.) Street: City/State/Zip: Telephone: Fax: Do you want a Certificate of Insurance sent to this location? 5. Does the Professional Corporation, Partnership, Sole Practitioner, or Fictitious Name Entity have any ownership interest in a hospital, nursing home, sanitarium, clinic, laboratory, any facility providing bed and board, and/or any other business enterprise? (No coverage is provided for ownership or administrative activities related to the above.) 6. Is the Professional Corporation, Partnership, Sole Practitioner, or Fictitious Name Entity in the business of managing or providing staffing to a hospital, nursing home, sanitarium, clinic, laboratory, any facility providing bed and board, and/or any other business enterprise? (No coverage is provided for management/administrative activities related to the above.) 7. Has the Professional Corporation, Partnership, Sole Practitioner, or Fictitious Name Entity been involved in a malpractice suit or claim (pending or closed) in the past seven years? If yes, please complete the Claims History supplemental application and attach copies of all pertinent documentation. 8. Have any claims or incidents ever been reported involving any of your employee/independent contractor professionals, partners and/or shareholders to any carrier? If yes, please complete the Claims History supplemental application and attach copies of all pertinent documentation. 9. Have any of your partners, shareholders, employee/independent contractor professionals ever been the subject of an investigation or disciplinary proceedings? If yes, please provide copies of all pertinent documentation and a detailed written explanation. SUPPLEMENTAL APPLICATION SUPPLEMENTAL APPLICATION 10. Have any of your partners, shareholders, employee/independent contractor professionals ever been charged with, convicted of, pleaded guilty or no contest to a felony? If yes, please provide copies of all pertinent documentation and a detailed written explanation. 11. Has the Professional Corporation, Partnership, Sole Practitioner, or Fictitious Name Entity ever had a settlement or judgment alleging undue familiarity, professional misconduct or assault in connection with undue familiarity? If yes, please complete the Claims History supplemental application and attach copies of all pertinent documentation. FAIR TPP0009 01 12 Page 1 of 5
12. Have any of your partners, shareholders, employee/independent contractor professionals ever had a settlement or judgment alleging undue familiarity, professional misconduct or assault in connection with undue familiarity? If yes, please complete the Claims History supplemental application and attach copies of all pertinent documentation. In order for coverage to apply, all shareholders and partners are required to carry their own individual professional liability insurance with limits of liability equal to or in excess of your coverage limits of liability. Additionally, a minimum of 50% of all licensed physician shareholders or partners must be insured with The Psychiatrists Program. 13. Partners and Shareholders Information: Total number of Partners or Shareholders: a) Name: Degree: Practices As: Date of Hire: Insurance Carrier: Coverage Limits of Liability: If insured with our program, please provide the Customer ID#: b) Name: Degree: Practices As: Date of Hire: Insurance Carrier: Coverage Limits of Liability: If insured with our program, please provide the Customer ID#: c) Name: Degree: Practices As: Date of Hire: Insurance Carrier: Coverage Limits of Liability: If insured with our program, please provide the Customer ID#: In order for coverage to apply, all employee/independent contractor professionals are required to carry their own individual professional liability insurance with limits of liability equal to or in excess of your coverage limits of liability. Additionally, a minimum of 50% of all licensed physicians must be insured with The Psychiatrists Program. 14. Employee/Independent Contractor Professionals Information: Total number of Employees/Independent Contractors: a) Name: Degree: Practices As: Date of Hire: Insurance Carrier: Coverage Limits of Liability: If insured with our program, please provide the Customer ID#: b) Name: Degree: Practices As: Date of Hire: Insurance Carrier: Coverage Limits of Liability: If insured with our program, please provide the Customer ID#: c) Name: Degree: Practices As: Date of Hire: Insurance Carrier: Coverage Limits of Liability: If insured with our program, please provide the Customer ID#: FAIR TPP0009 01 12 Page 2 of 5
DECLARATIONS 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. NOTICE TO 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 ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO ARKANSAS, NEW MEXICO 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. 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 POLICYHOLDER 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 DEFRAUDING THE INSURER OR 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. 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. NOTICE TO ILLINOIS APPLICANTS: THE DISCOVERY OF ANY FRAUD, INTENTIONAL CONCEALMENT, OR MISREPRESENTATION OF MATERIAL FACT IN THE POLICY WILL RENDER THIS POLICY, IF ISSUED, VOID AT INCEPTION. THE DISCOVERY OF ANY FRAUD, INTENTIONAL CONCEALMENT, OR MISREPRESENTATION OF A MATERIAL FACT DURING A CLAIM WILL RENDER THIS POLICY, IF ISSUED, CANCELLED. 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 THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. FAIR TPP0009 01 12 Page 3 of 5
NOTICE TO LOUISIANA 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 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 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. NOTICE TO MINNESOTA APPLICANTS: A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. 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 APPLICATION 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 (365:15-1-10, 36 3613.1). NOTICE TO OREGON 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, MAY BE GUILTY OF A FRAUDULENT ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO 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. NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN FAIR TPP0009 01 12 Page 4 of 5
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. NOTICE TO VERMONT 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 ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. Physician s Personal Signature Date The Psychiatrists Program 1401 Wilson Boulevard, Suite 700 Arlington, VA 22209 Name of Agent: License #: Signature: Date: FAIR TPP0009 01 12 Page 5 of 5