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 Coverage Information Proposed Effective Date: Retroactive Date: Requested Limits of Liability: : General Liability: Requested Deductible: Other Coverages 0 Defense Outside Limits 0 Punitive Damages 0 Physical & Sexual Abuse 0 Hired & Non-Owned Auto Annual Gross Receipts Estimated Next 12 Months: Last 12 Months: Annual Remuneration Estimated Next 12 Months: Last 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 2015-5-18 Page 1 of 12 www.grnhll.com
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 Breakdown of patient services (%) by outpatient visits: AIDS: Gynecology: Pediatric: Alcoholic: Hemodialysis: Physical Rehab: Bariatric: Holistic Medicine: Psychiatric: Communicable: Major Surgery: Research/Experimental: Dental: Minor Surgery: Stress Testing: Disability: Nutritional(diet): Substance Abuse: Drug Addiction: Obstetrical: Other(describe): Emergency Med.: Occupational: Family Planning: Optometry: General Exams: Orthopedic: Indicate the number of professional employees, volunteers, and independent contractors. (If none, state none): 2015-5-18 Page 2 of 12 www.grnhll.com
Exposures (cont.) Physicians, Surgeons and Dentists # Employees and Volunteers # Independent Contractors Physicians: No Surgery (other than incisions of boils, suturing of skin, or other obstetrical procedures) Physicians: Minor surgery or obstetrical procedures not constituting major surgery Proctologists, Ophthalmologists, and Urologists General Surgeons, Cardiac Surgeons, and Otolaryngologists (no plastic surgery) Obstetrics-Gynecologists, Plastic Surgeons, and Otolaryngologists doing plastic surgery Anesthesiologists, Thoracic Surgeons, Vascular Surgeons, Neurosurgeons, and Orthopedic Surgeons Physicians & Surgeons Assistants, Nurse Practitioners (describe duties on a separate sheet) Unlicensed Interns Dentists (no oral surgery) Orthodontists Oral Surgery IF ANY OF THESE CATEGORIES ARE PROVIDING SERVICES, COMPLETE PHYSICIAN EXPOSURE SUPPLEMENT. 2015-5-18 Page 3 of 12 www.grnhll.com
Exposures (cont.) - Allied Health Professionals Position # Employees & Volunteers # Independent Contractors Position # Employees & Volunteers # Independent Contractors Chiropractor Pharmacist Dental Hygienist Physical Therapist EEG/EKG Tech Physician s Assistant Med. Lab Tech Podiatrist Nurse Anesthesist Social Worker Nurse Midwife Psychotherapist Nurse Practitioner Radiation Tech. Occupational Therapist Respiratory Therapist Optician/ Optometrist RN, LVN, LPN Perfusionist Speech Therapist Dialysis Technician Surgical Technician Are all of the above licensed in accordance with applicable state and federal regulations? 0 Yes 0 No If no, please attach explanation. Describe hiring and verification processes for all employed/independently contracted physicians. Does the applicant desire to provide coverage for independent contractor(s), including them as additional insured(s) on their policy while working on their behalf? 0 Yes 0 No Does the applicant supervise any individuals other than those listed above? 0 Yes 0 No If yes, on a separate sheet provide detailed explanation of responsibilities and relationship to the entity which employs these individuals. Also, indicate by profession the number of individuals supervised. Does the applicant maintain any beds for overnight occupancy? 0 Yes 0 No If yes, please indicate the number, type, and the number of patients in the last 12 months. 2015-5-18 Page 4 of 12 www.grnhll.com
Exposures (cont.) - Outpatient Visits/Tests by Category Clinics - Total Physician Dentists Type Next Twelve Months Last Twelve Months Physician Asst/Nurse Practitioner Other Allied Health Professionals Laboratory Emergency Room Surgery (procedures) Imaging/X-Ray Other: (please specify) Exposures (cont.) Does the clinic provide medical services for other than a service fee? 0 Yes 0 No If yes, give details of arrangements, including a copy of the contract(s). What is the patient % make up? Fee for service: Prepaid: What percentage of prepaid patients are referred to outside physicians? 2015-5-18 Page 5 of 12 www.grnhll.com
Exposures (cont.) Does the applicant perform: Acupuncture or acupuncture anesthesia? 0 Yes 0 No Explain: Angiography/Arteriography/Venography? 0 Yes 0 No Explain: Catheterization (other than urinary or umbilical)? 0 Yes 0 No Describe procedure: Closed reduction of compound fractures and/or Dermabrasion? 0 Yes 0 No Injection of radioisotopes and/or use of irradiated substances? 0 Yes 0 No Describe: Radiation Therapy and/or Chemotherapy? 0 Yes 0 No Describe: Electroconvulsive Therapy? 0 Yes 0 No Silicone Injections? 0 Yes 0 No Describe: Laser Treatment? 0 Yes 0 No Describe: Experimental procedures or research testing? 0 Yes 0 No Describe in detail on separate sheet. Hypnosis? 0 Yes 0 No Describe: X-Ray Services? 0 Yes 0 No If yes, number of annual X-Ray exposures for diagnosis: For treatment: What qualifications are required of the staff? Does the applicant prescribe drugs for weight reduction of patients? 0 Yes 0 No 2015-5-18 Page 6 of 12 www.grnhll.com
Exposures (cont.) Are any of the following performed? Obstetrics Pre-natal? 0 Yes 0 No Deliveries? 0 Yes 0 No Elective or therapeutic abortions? 0 Yes 0 No If clinic provides pre-natal care only, do clinic physicians or nurse midwife attend patient at designated hospital at time of delivery? 0 Yes 0 No If the answer to the previous question is no, are clinic pre-natal records provided to delivering physician and to the designated hospital prior to delivery? 0 Yes 0 No Chemical/Substance Abuse Services Counseling? 0 Yes 0 No Methadone or similar substances dispensed or prescribed? 0 Yes 0 No If the previous answer is yes, describe on a separate sheet the treatment and controls used, and indicate number of treatments during the last twelve months as well as estimates for the next twelve months. Do you provide home health care services? 0 Yes 0 No If yes, do they account for more than 5% of your gross revenue? 0 Yes 0 No If yes, please complete and attach our Home Health Care Service Application. Is your facility owned by an M.D.? 0 Yes 0 No If yes, owner name(s): Is the applicant in the employ of any federal governmental entity? 0 Yes 0 No If yes, please attach explanation. Name and give any locations of hospitals or institutions the applicant uses in practice and describe how affiliated. In what states is the applicant registered and licensed to practice? Does the applicant own (wholly or in part), operate, or administer any hospital, nursing home, or other institution where medical services are customarily rendered? 0 Yes 0 No If yes, give details, including name, location, size, and number of beds. Does the applicant own or operate any business other than that shown in the previous question? 0 Yes 0 No 2015-5-18 Page 7 of 12 www.grnhll.com
Exposures (cont.) If yes, please give details on a separate sheet. Does applicant perform or engage in any surgical procedure(s) in their professional office or similar non-hospital facility? Please submit a detailed list of all surgical procedures performed at the center. Provide the number of procedures performed during the last 12 months for each listed above. For each procedure, break down the number performed under general anesthesia (including IV sedation) versus local (topical of local infiltration) Is anesthesia (other than topical or by means of local infiltration) administered by the applicant? 0 Yes 0 No If yes, describe in detail by whom, whether employed or contracted, a list of agents utilized, whether an oximeter is used, and attach a copy of the written policies and/or guidelines of the anesthesia service. If a CRNA administers anesthesia, include the CRNA under the Physician Exposure Supplement. Does the applicant perform any: Surgery other than incision of superficial boils or suturing superficial fascia? 0 Yes 0 No Circumcisions and/or dilation and curettage and/or insertion of temporary pacemakers? 0 Yes 0 No Tonsillectomies and/or Adenoidectomies and/or Caesarean Sections? 0 Yes 0 No Cosmetic Plastic Surgery? 0 Yes 0 No Desribe: Surgery for weight reduction of patients? 0 Yes 0 No Abortions and/or menstrual extractions? 0 Yes 0 No Describe (include trimester, method, and number of abortions performed per month) Cryosurgery (other than use on benign or pre-malignant dermatological lesions)? 0 Yes 0 No Describe: Silicone Implants? 0 Yes 0 No Describe: Sterilization procedures? 0 Yes 0 No Describe: Biopsies and/or endoscopies? 0 Yes 0 No List types performed: Sex change operations? 0 Yes 0 No Describe and advise number yearly: Experimental surgery or surgical research? 0 Yes 0 No Describe on a separate sheet. Other Surgery? 0 Yes 0 No Describe 2015-5-18 Page 8 of 12 www.grnhll.com
Exposures (cont.) Does the applicant have the following equipment at the center: Laboratory with the following capabilities - CBC, UA electrolytes, blood sugar, arterial blood gases, pregnancy test, bun, and/or creatinine 0 Yes 0 No X-ray with on premises processing 0 Yes 0 No EKG - 12 lead 0 Yes 0 No Monitor/Defibrillator 0 Yes 0 No Crash cart with full cardiac life support capabilities and necessary intravenous fluids 0 Yes 0 No Appropriate trays and equipment for accessing the airway, pericardiocentesis, needle thoracostomy, transvenous or transthoracic, pacemaker, venous access, gastric lavage 0 Yes 0 No Oxygen 0 Yes 0 No Suction 0 Yes 0 No Pneumatic anti-shock trousers 0 Yes 0 No Dedicated telephone line to the closest appropriated hospital emergency department and/or two-way communication with the EMS 0 Yes 0 No Describe peer review process for surgeons on a separate sheet. Does the applicant perform gynecology: Surgical? 0 Yes 0 No Family Planning? 0 Yes 0 No If yes, indicate number of patients: Describe range of services: Risk Management Name, qualifications, and number of years of experience of the Medical Director: Who does the supervising of staff, and what is his/her experience? Does your clinic require that professional staff be CPR trained? 0 Yes 0 No Describe the referral source(s) by which patients are directed to the entity. Does the clinic have a written policy and procedure to assure that contractors credentials, liability insurance coverage, and standards of performance are commensurate with the entity s? 0 Yes 0 No 2015-5-18 Page 9 of 12 www.grnhll.com
Risk Management (cont.) Do you contracts with vendors specify responsibilities, performance goals, warranties, liability insurance, and possible termination by either party? 0 Yes 0 No Is the applicant eligible for certification or accreditation? 0 Yes 0 No If yes, is the applicant certified and/or accredited? 0 Yes 0 No If no, please explain the reason: Is the applicant approved to receive Medicare and Medicaid payments? 0 Yes 0 No Does the applicant have a qualified physician(s) and other personnel trained in emergency medical care in the center during all hours of operation? 0 Yes 0 No Please describe: Do you have any restricted licensed physicians on staff? 0 Yes 0 No If yes, please explain on a separate sheet. Do you have any physicians on staff that do not maintain staff privileges at a hospital? 0 Yes 0 No If yes, explain. Does the applicant participate in any activity (e.g. newspaper columns, broadcasts, etc.) whereby professional advice is offered to the public? 0 Yes 0 No If yes, please attach a detailed explanation of this activity. Does the applicant advertise their professional services in any manner (other than a simple listing in a telephone directory)? 0 Yes 0 No If yes, attach a copy of ALL of the advertisements. Is the applicant associated with any agency or organization that engages in any kind of advertising for, or soliciting of, patients? 0 Yes 0 No If yes, attach detailed explanation and a copy of ALL of the advertisements. Does the applicant use a collection agency? 0 Yes 0 No If yes, give name of agency: Does the agency have the authority to file a collection suit at its discretion? 0 Yes 0 No Is the applicant and all professional employees licensed in accordance with applicable state and federal laws? 0 Yes 0 No If no, attach explanation of any exception. 2015-5-18 Page 10 of 12 www.grnhll.com
Other Information (Explain any Yes answers on a separate sheet) Has the applicant or any of its employees: Ever been the subject of disciplinary or investigatory proceedings or reprimanded by an administrative or governmental agency or a hospital professional association? 0 Yes 0 No Had any professional license refused, suspended, revoked, or renewal refused or accepted only with special terms, or has the applicant or any of its employees voluntarily surrendered any professional license? 0 Yes 0 No Been convicted for an act committed in violation of any law or ordinance other than traffic offenses? 0 Yes 0 No Have any claims been made or occurrences reported during the past six 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 (other than listed above) 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 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 Agency/Broker Information Agency Name: Broker/Contact Name: Telephone: 2015-5-18 Page 11 of 12 www.grnhll.com
PHYSICIANS EXPOSURES SUPPLEMENT INSTRUCTIONS: COMPLETE THIS SUPPLEMENT IN ITS ENTIRETY. IF A SPECIFIC ITEM IS NOT APPLICABLE, STATE N/A. IF THE SPACE PROVIDED IS INSUFFICIENT TO COMPLETE THE ITEM, ATTACH A SEPARATE SHEET. PLEASE NOTE THIS SUPPLEMENT IS PART OF THE APPLICATION AND ALL WARRANTIES AND STATEMENTS CONTAINED THEREIN APPLY TO THIS SUPPLEMENT. CREDENTIALING Is there a written policy and procedure for credentialing of physicians, surgeons, and dentists who provide professional services at your entity? 0 Yes 0 No If yes, attach a copy of the policy and procedure. If no, describe in detail your entity s credentialing process. INSURANCE VERIFICATION Does your entity require proof of insurance of physicians, surgeons, and dentists? 0 Yes 0 No If yes, does the entity determine the type of coverage (occurrence of claims made)? 0 Yes 0 No If yes, does the entity require those with claims made coverage to purchase the tail if the policy is cancelled? 0 Yes 0 No PHYSICIAN LISTING List by individual profession each physician, surgeon, and dentist who provides professional services at your entity. Include all types (employed, contract, staff). Indicate Limit of carried by each. ADDITIONAL STAFFING Does the entity anticipate employing or contracting with any additional physicians, surgeons, or dentists during the next 12 months? 0 Yes 0 No LARGE CLAIM Has any of the entity s physician staff had a claim or suit where the indemnity payment or reserve is greater than $10,000? 0 Yes 0 No Date Applicant Title 2015-5-18 Page 12 of 12 www.grnhll.com