8
8
Quality Physicians Insurance Program
Please answer all questions and sign and date the application. If a question does not apply to you,please answer N/A. The following must accompany the application:
________ CV
________ State & DEA License
________ Current Insurance Policy Declaration Page
________ Insurance company generated Loss Runs for
the past 10 years, if applicable
________ Carefirst Quality Rewards (CQR) Scorecard, and/or ________ Other Measurable Quality Criteria
Strategy Management Insurance, LLC 10075 Red Run Boulevard, Suite 500
Owings Mills, Maryland 21117 Main Office 443.548-5800
Fax 443.548-2680
Physician Application
QPIP Physician Application
For Surplus Lines Coverage
SECTION I: PERSONAL INFORMATION
1. Last Name _______________________________ First Name _________________________________ M.I. ________ 2. Date of Birth: __________________________________ 3. Social Security Number: _________________________ 4. Residence Address:
Street:______________________________________________________________________________________________ City/State/Zip/County: ________________________________________________________________________________ 5. Residence Telephone: (________) __________________ 6. E-Mail _________________________________________
SECTION II: PRACTICE INFORMATION
1. Primary Office Address:
Street:______________________________________________________________________________________ City/State/Zip/County: _________________________________________________________________________ 2. Office Telephone: (________) ______________________________
3. Number of years at current office location: _______________ 4. Percent of practice at this location: ______________ 5. List all other office locations where you will practice your profession:
Secondary Office Address:
Street:_______________________________________________________________________________________ City/State/Zip/County: _________________________________________________________________________ Tertiary Office Address:
Street:_______________________________________________________________________________________ City/State/Zip/County: _________________________________________________________________________
6. Type of Practice for which you are requesting coverage (check all that apply):
Partnership – Name of partnership: ____________________________________________________________ Employed doctor – Name of employer: _________________________________________________________ Independent contractor – Name of physician, partnership or corporation with whom you contract:
IH Phys App 061609 3 Medical Director of __________________________________________________________________________ Individual/Solo corporation – Name of corporation: _______________________________________________ Other _____________________________________________________________________________________ 7. Have you entered into any agreements to supervise or collaborate with any person (including physician extender) or entity other than above? _____Yes _____No If yes, please include details on a separate sheet.
8. Do you request coverage for your corporation? Yes No
9. Requested effective date: ____________________ Prior Acts Date (Retroactive Date) ______________________ 10. Requested limits of liability (per claim/aggregate):
$1,000,000/$3,000,000 $2,000,000/$6,000,000 Other: $____________________ 11. Deductible (per claim/aggregate):
None $10,000/$30,000 $25,000/$75,000 Other:$____________ 12. Briefly describe the professional activities for which you are requesting coverage:
____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 13. How many hours per week do such activities involve? _____________________________________________________ 14. Other than the activities described above, do you currently render, or plan to render, any other medical professional services elsewhere? ______Yes ______No If yes, please describe these activities:
___________________________________________________________________________________________________ 15. Do you have insurance coverage for the other activities described above? ______Yes ______No ______N/A
If yes, please provide the name of the insurance carrier: ____________________________________________________ PLEASE ATTACH A COPY OF INSURANCE DECLARATION PAGE
SECTION III: MEDICAL TRAINING AND HISTORY
1. Undergraduate College/University: ___________________________________________________________________ City: _____________________ State: _________ Country: ______________ Year graduated: _________________ 2. Medical School: __________________________________________________________________________________ City: _____________________ State: _________ Country: ______________ Year graduated: _________________ 3. If you are a graduate of a foreign medical school:
Are you certified by the Education Council for Foreign Medical Graduates? Yes No Have you passed the United States Medical License Exam (USMLE)? Yes No
4. Internship (Name of institution): ____________________________________ City/State: __________________________ From: ______________________________ To: __________________________________
Specialty: ___________________________ Internship completed? Yes No
If “No” , explain: ________________________________________________________________________________ 5. Residency (1) (Name of institution): _________________________________ City/State: __________________________ From: ______________________________ To: __________________________________
Specialty: ___________________________ Residency completed? Yes No
If “No” , explain: ________________________________________________________________________________ 6. Residency (2) (Name of institution): __________________________________ City/State: _________________________ From: ______________________________ To: __________________________________
Specialty: ___________________________ Residency completed? Yes No
If “No” , explain: ________________________________________________________________________________ 7. Fellowship (Name of institution): ____________________________________ City/State: __________________________ From: ______________________________ To: __________________________________
Specialty: ___________________________ Fellowship completed? Yes No
If “No” , explain: ________________________________________________________________________________ 8. Hours of Continuing Medical Education (CMEs) completed within each of the last two (2) years?
_______________________________________________________________________________________________ _______________________________________________________________________________________________
IH Phys App 061609 5
SECTION IV: MEDICAL PRACTICE LICENSES & CERTIFICATIONS
1. Licensing Information – List all States in which you are Licensed to Practice Medicine:
STATE LICENSE NUMBER STATUS EXPIRATION DATE
2 Narcotics/DEA License #: _______________ Expiration date: ________________ Status: __________________ 3. Have there been any changes in your specialty, classification or practice activity within the last 5 years?
Yes No If “Yes”, explain: _______________________________________
4. Are you Board Certified? Yes No 5. Board Name (1):
________________________________________________________________________________________________ Date Certified _______________ Expiration Date _______________________ Board Name (2):
________________________________________________________________________________________________ Date Certified _______________ Expiration Date _______________________
6. If you are not Board certified, are you eligible to take the boards in your specialty? Yes No Do you plan to take the Board exam (both written and oral exams)? Yes No When do you plan to take the Board exam? ___________________
7. Have you ever been denied Board certification or recertification or have you allowed your certification to lapse? If “Yes”, state reason: _____________________________________________________ Yes No
SECTION V: RISK RATING INFORMATION (these definitions are not all inclusive) SURGERY DEFINITIONS: CHECK ONLY ONE CATEGORY % PERCENT PRACTICE No Surgery – Includes normal office procedures as commonly found in a family
practice. Incision of boils and superficial abscesses, suturing of skin, and superficial fascia, any similar minor procedures encountered in a normal family type practice shall be considered “No Surgery”. This includes administration of local or topical anesthesia and circumcision. No invasive procedures or special procedures room activities are done.
□
Minor Surgery – Includes all listed in definition of “No Surgery”, as well as assisting
in major surgery, D&C, and vasectomies. Invasive procedures are done, but the
procedures do not open or enter a major body cavity.
□
Major Surgery – Includes operations in or upon any body cavity including but not
listed to the cranium, thorax, abdomen or pelvis, any other operation, which because of the condition of the patient or the length or circumstances of the operation presents a distinct hazard to life, removal of tumors, plastic surgery, tonsillectomies,
adenoidectomies, cesarean sections, and any other operation done using general anesthesia, and the administration of anesthesia other than local or topical.
□
2. Check all that apply to the practice for which you are applying for insurance coverage: Assist in major surgery on your own patients
Assist in major surgery on other than your own patients Administer general anesthesia
Perform elective cosmetic surgery
Reduction of displaced fractures and/or dislocations
Practice in hospital ER, other than when called to see your own patient or as required staff rotation Practice in “walk in” or extended hours clinic
Endoscopic procedures, other than proctoscope or flexible sigmoidoscope Prenatal care Non-surgical obstetrics Caesarian sections Tubal ligations D & C Vasectomies Acupuncture IVP’s
Interventional Pain Management Procedures
4. Have you ever performed obstetrics but no longer do so? ________Yes _______No If yes, when did you discontinue obstetrics? _____________
IH Phys App 061609 7 6. Pathologists: Do you currently, or do you plan to receive specimens from outside your home state? ____Yes ____No
If yes, which state(s) will the specimens be coming from? _________________________________________________ 7. Check all procedures you perform and note where each procedure is performed (office, hospital, surgery center) and number of procedures per year.
Procedure Where Performed Approximate Number Per Year
_____Elective Abortions _____________________________________________________________ _____Bariatric Surgery _____________________________________________________________ _____Nerve Blocks _____________________________________________________________ _____Epidural injections _____________________________________________________________ _____Cosmetic/aesthetic procedures/surgery _____________________________________________________________ _____ Obstetrical deliveries at _____________________________________________________________
Other than acute care facility
8. List all hospitals where you have privileges or have applied for privileges.
HOSPITAL CITY/STATE TYPE OF PRIVILEGES CERTIFICATE
NEEDED-Y/N
9. Do you, your partnership or corporation, employ any of the following non-physician providers? If yes, please complete the information below. Indicate the number of each type of professional employed or contracted by the physician. Use a separate sheet, if necessary:
Non-Physician Providers Number at Primary Location Number at Other Locations
Nurse Anesthetists Nurse Practitioners
Nurse Midwives, including deliveries Nurse Midwives, no deliveries
Perfusionists
Physician’s Assistants Psychologists
Optometrists
Other Extenders (specify)
10. Please check an option below regarding physician extenders:
I would like to apply for Extender Employee Medical Professional Liability Coverage on a shared limits basis I would like to apply for Extender Employee Medical Professional Liability coverage on an individual limits basis I do not wish to apply for Medical Professional Liability coverage for my Extender Employees
SECTION VI: INSURANCE HISTORY
1. Current carrier name: __________________________________________________ Claims Made Occurrence Effective date: _________________ Expiration date: ___________________ Prior Acts Date: __________________ Limits of liability: $__________________ Per Claim ________________________Aggregate
Deductible SIR $: ___________________Per Claim ______________________Aggregate Annual premium: ________________________
First prior carrier name: ___________________________________________________ Claims Made Occurrence Effective date: ________________ Expiration date: _____________ Prior Acts Date: _______________________ Limits of liability: ___________________Per Claim ________________________Aggregate
Deductible SIR $: ___________________Per Claim ________________________Aggregate
Second prior carrier name: ________________________________________________ Claims Made Occurrence Effective date: ________________ Expiration date: _____________ Prior Acts Date: _______________________ Limits of liability: ___________________Per Claim ________________________Aggregate
Deductible SIR $: ___________________Per Claim ________________________Aggregate
2. If you are currently insured on a claims made policy, are you obtaining Extended Reporting Period (tail) Coverage from your current insurance carrier? Yes No
Note: To prevent possible gaps in your Claims Made coverage, either Extended Reporting Period Coverage from your current insurer, or Prior Acts coverage fromIronshoremust be purchased. Prior Acts coverage is subject to
underwriting approval and may not be available to all applicants.
3. Where have you practiced your profession since completion of your formal training? (include military or any public service organization) Account for all time since medical school. Explain any gaps in your education or professional
practice history. If your attached CV provides the same information, go on to the next question.
City/State: _______________________ From: ________________________ To: ___________________ Solo practitioner Part of a group Group name: ________________________________________ City/State: _______________________ From: ________________________ To: ___________________ Solo practitioner Part of a group Group name: _________________________________________ City/State: _______________________ From: ________________________ To: ____________________ Solo practitioner Part of a group Group name: _________________________________________
IH Phys App 061609 9
SECTION VII: UNDERWRITING INFORMATION
If you answer “Yes” to any of the questions below, provide a detailed explanation on a separate sheet of paper, Supplemental Claim Information Form, or in the Comment section provided as appropriate.
Within the past 10 years:
1. Are you being investigated or have you been convicted of a misdemeanor (other than traffic related) or felony or is any such charge pending?
Yes No 2. Have you been admitted to or sought treatment from any mental health or chemical/substance
abuse program?
Yes No 3. Has your license or certification been denied, restricted, suspended, revoked, surrendered, put
on probation or issued on a restricted basis?
Yes No 4. Have your privileges been denied, restricted, suspended, revoked or put on probation by any
health care facility?
Yes No 5. Have you ever resigned from a health care facility while under investigation or to avoid
possible disciplinary action?
Yes No 6. Has any hospital as a result of reviewing your patient care or your performance, conducted a
hearing or taken any action concerning your medical staff membership/privileges or required additional supervision?
Yes No 7. Have any complaints been registered against you with your state licensing body, regulatory
body, professional association, employer or healthcare facility at which you practice(d)?
Yes No 8. Have you ever had a complaint, claim or suit brought against you for alleged sexual
misconduct?
Yes No 9. Have Medicare or Medicaid authorities ever investigated or brought charges against you? Yes No 10. Have you provided any professional services without professional liability insurance? Yes No 11. Have any insurers canceled coverage, declined coverage, refused renewal or renewed only
under restrictive circumstances your professional liability coverage?
Yes No 12. Have you ever treated any patients by means of unconventional therapeutics, or utilized FDA
experimental drugs other than through Institutional Review Board (IRB) approved research programs? Yes No COMMENTS: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________
SECTION VIII: CLAIMS INFORMATION
If you answer “Yes” to any of the questions below, provide a detailed explanation on a separate sheet of paper, Supplemental Claim Information Form, or in the Comment section below as appropriate.
Within the past 10 years:
1. Have you been involved in a malpractice claim, lawsuit, incident or occurrence in the last 10 years? If “Yes”, how many? _______
Yes No 2. Are you aware of any circumstances that may result in a malpractice claim or suit being made
or being brought against you?
Yes No 3. Are you aware of any outstanding incidents, claims, or suits (even if you believe the
outstanding claim or suit would be without merit) that have not been reported to your current or prior professional liability carrier?
Yes No 4. Have you been contacted by a plaintiff’s attorney or required to produce medical records or
statements regarding any case you have been involved with, regardless of whether you have been specifically named in the suit or claim?
Yes No COMMENTS ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________
IH Phys App 061609 11
SECTION IX: AUTHORIZATION
I have answered the questions in the Application to the best of my ability and declare that, to the best of my
knowledge, the statements set forth herein are true and correct. My signing of the Application shall be the basis of the contract should a policy be issued. I agree to notify the Company of any change in my practice of medicine within thirty (30) days of its occurrence, including but not limited to the following:
A. A change in specialty or medical procedures performed;
B. A change in location of practice, including exposures generated through telemedicine or out-of-state patients; C. Investigation, restriction, suspension or surrender of any state medical, DEA license or hospital privileges; D. Any physical or mental condition, illness or defect, including treatment for alcohol or substance abuse not previously disclosed to the Company in writing.
E. Conviction, plea or agreement related to any charges of a misdemeanor or felony (including DUI, DWI, OUI) other than minor traffic offenses.
This application is for insurance to be placed on a surplus lines basis with Ironshore Specialty Insurance Company.
____________________________________________ _____________________________ ____ Applicant’s Signature Date
____________________________________________ Print Name
SUPPLEMENTAL CLAIMS FORM
ALL QUESTIONS MUST BE ANSWERED AND SIGNED AND DATED. PLEASE COMPLETE SEPARTATE FORM FOR EACH CLAIM.
1. Name of patient: ______________________________________ Age: _________ Male Female 2. Describe the allegation made by claimant: ______________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 3. Date claim was made or filed: ______________________ 4. Date of alleged incident:__________________________ 5. Insurance company:_________________________________________________________________________________ 6. Additional defendants: ______________________________________________________________________________ 7. Disposition of claim: Open Closed
8. Is claim in suit? Yes No If “Yes”, amount asked in summons: $______________ If closed: Date closed: _________________
Court judgment Out of court settlement Dismissed with prejudice Dismissed without prejudice Total indemnity paid (including deductible) $______________________ Total defense costs/ expenses paid $______________________
Total costs incurred $______________________
PROVIDE COMPLETE & DETAILED INFORMATION. USE ADDITIONAL SHEETS IF REQUIRED.
9. Condition and diagnosis at time of incident (include dates of visits) ___________________________________________ ____________________________________________________________________________________________________ 10. Description of treatment rendered (include dates of visits) __________________________________________________ ____________________________________________________________________________________________________ 11. Condition of patient subsequent to treatment (include dates of follow-up treatment) ______________________________ ____________________________________________________________________________________________________
IF OPEN: $AMOUNT
Claimant’s settlement demand Defendant’s offer for settlement Insurer’s loss reserve
IH Phys App 061609 13
QPIP PURCHASING GROUP, INC. MEMBERSHIP AGREEMENT
QPIP Purchasing Group, Inc. (the “Purchasing Group”) was organized pursuant to the Liability Risk Retention Act of 1986 to serve as a vehicle for the group purchasing of professional liability coverage for its members. The following constitutes the Membership Agreement of the Purchasing Group. Execution of this Application for Insurance constitutes acceptance of the terms of the Membership Agreement.
1. The Applicant acknowledges that he/she desires to become a member of the Purchasing Group in order to facilitate his/her purchase of professional liability insurance.
2. The Purchasing Group may require the payment of an annual membership fee, which may be adjusted from time to time by the Purchasing Group in its sole discretion.
3. The Purchasing Group may offer various benefits to its members. The Purchasing Group, at its sole discretion and at any time, may add, change or discontinue any benefit programs that it offers to its members.
4. The Applicant acknowledges that his/her membership in the Purchasing Group does not confer any specific rights or benefits and that his/her membership in the Purchasing Group is personal to the Applicant and may not be transferred or assigned to any other person or entity.
5. The Applicant acknowledges that there is no guarantee of continued availability of professional liability insurance by virtue of his/her membership in the Purchasing Group, and that the decision to offer coverage to him/her is made by the insurance company from which such insurance is procured and is subject to the rates and terms and conditions offered by such insurance company. Failure to meet the underwriting criteria of the insurance carrier may result in the non-renewal of insurance coverage.
6. The Applicant acknowledges that membership in the Purchasing Group is governed by the Bylaws and Membership Rules of the Purchasing Group, copies of which will be provided to the Applicant upon request.
7. The Purchasing Group may select an administrator to administer its business affairs. The Purchasing Group shall have exclusive authority and discretion to select and terminate the administrator and to negotiate the administrator’s compensation. The Applicant agrees not to dispute the selection of the administrator or the compensation paid to the administrator.
8. The Purchasing Group may select an agent to administer its insurance program. The Purchasing Group shall have exclusive authority and discretion to select and terminate the agent and to negotiate the administrator’s compensation. The Applicant agrees not to dispute the selection of the agent or the compensation paid to the agent.
9. The Purchasing Group shall select the general insurance terms, conditions and exclusions of the insurance program provided to its members in its sole discretion.
10. The Applicant acknowledges that policy dividends or credits, if any, may be determined by reference to the underwriting results of members of the Purchasing Group in different geographic regions and that such dividends or credits, if any, may vary among members depending on the geographic region in which the member is located.
11. The Applicant’s membership in the Purchasing Group will automatically terminate without further action of the parties: (i) as of the date of expiration or termination of the Applicant’s coverage under policies of insurance issued or placed through the Purchasing Group; or (ii) upon failure of the Applicant to pay the annual membership fee or any premiums for insurance obtained through the Purchasing Group when such amounts are due; provided, however, that upon payment of past due premium or membership fees, the Purchasing Group may, in its sole discretion, reinstate the Applicant’s membership; or (iii) upon the Applicant’s withdrawal from the Purchasing Group pursuant to Section 13.
12. The Applicant’s membership may be terminated by the Purchasing Group upon thirty days notice if there is a change in the business of the Applicant so that it would no longer qualify for membership within the requirements of the Liability Risk Retention Act.
13. The Applicant may withdraw from the Purchasing Group at any time by submitting written notice of its withdrawal to the Purchasing Group stating the date on which the withdrawal is to be effective. The Applicant acknowledges that
withdrawal from the Purchasing Group will immediately terminate all insurance coverage provided to the Applicant through the Purchasing Group.
14. The Applicant agrees to indemnify and hold harmless the Purchasing Group for any liability or expenses, including costs of defense, that the Purchasing Group may incur as a result of actions or omissions of the Applicant or any of the Applicant’s employees or agents, including incorrect or false statements of fact intentionally made to the Purchasing Group. 15. This Agreement is governed by and shall be construed in accordance with the laws of the State of Maryland, without regard to any applicable choice of law provisions.
____________________________________________ _________________________________ Applicant’s Signature Date
____________________________________________ Print Name