MEMORIAL
Captive Insurance Program
1
Allied Health Personnel
Professional Liability Insurance Application
Separate Limits
Shared Limits
In addition to a completed Application, please provide the following documents:
• Copy of Current License
Claims-Made
Claims-Made coverage is limited to liability for injuries for which claims are first made during the policy period, for services
rendered between the retroactive date and expiration date of the policy. Please contact the Underwriting Department if you have
questions pertaining to the differences between claims-made and occurrence coverage or the additional expense associated with an
extended reporting endorsement ( “tail coverage”).
Instructions: Complete all questions. If the answer to any question is “No”, be certain to check the box. Do not leave a question unanswered. If additional space is required to answer any question, use the “Additional Information” section located at the end of this Application or attach supplemental pages. Please sign, date and forward completed Application.
1. Applicant Name:
First Middle Last Title
Male Female
2. Name of Employer:
First Middle Last Title
3. Effective date of coverage (12:01 a.m. Standard Time):
Month Day Year
4. Retroactive date for prior acts coverage only (12:01 a.m. Standard Time):
Month Day Year
MEMORIAL
Captive Insurance Program
5. Profile Questions (answer all questions)
NOTE: If answer is “Yes” please provide written explanation.
YES NO
a. Has your professional liability insurance ever been canceled for non-payment, declined, canceled, non-renewed, or issued on terms (including, but not limited to: restrictive endorsements, surcharges premium, etc.)?
b. Have you treated any patients by means of unconventional therapeutics which could be
considered human experimentation? If “Yes”, indicate treatment(s) and name(s) and address(es) of sponsoring institution(s) or entity(ies):
c. Have any of your hospital privileges ever been denied, modified, suspended, revoked, non- renewed or accepted on a restricted basis or have you ever been subjected to probation, reprimand, censure, sanction or other disciplinary action as a result of a hospital committee investigation or inquiry?
d. Have you ever been subjected to probation, suspension, reprimand, censure, sanction or other disciplinary action as a result of any governmental agency, medical or professional society disciplinary or administrative proceedings?
e. Has membership in any medical society or professional organization ever been denied, suspended, revoked, voluntarily surrendered or accepted on a restricted basis?
f. Have you ever been convicted of an act committed in violation of any law, statute or ordinance, including a conviction for driving while intoxicated (DUI), excluding other traffic offenses?
g. Has your license to practice medicine or prescribe controlled substance ever been suspended, revoked, voluntarily surrendered, reprimanded, fined or subjected to probationary terms? If “Yes”, indicate which: _ Medical License _ Controlled Substance License
h. Have you ever incurred, become aware of having, or had an allegation made against you of having any illness or physical disability that impairs or potentially could impair your ability to practice medicine or your the central nervous system, organic brain disease, convulsive orders, multiple sclerosis, rheumatoid arthritis, infectious disease, etc.?
i. Has any malpractice claim or suit been brought against you within the past ten (10) years? If “Yes”: i) Please complete the Claim Information Supplement for each claim/suit brought against you in the past ten (10) years.
ii) If a claim/suit occurred within the past five (5) years, please complete the Claim Information. Supplement and submit complete copies of all office/hospital records, summons and complaint, etc
iii) If a claim/suit resulted in an indemnity payment within the past three (3) years, regardless of when it occurred, please submit all information specified in “ii”.
3
Certificate(s) of Insurance Duplicate this page as required
6. If your insurance request is accepted, evidence of your coverage is provided to a hospital, employer, etc. by issuing a
Certificate of Insurance. If you wish to have a Certificate of Insurance issued to a third party, please complete the following:
Name of Certificate Holder Name of Certificate Holder
Street Address Street Address
City State Zip City State Zip
Please circle one: Please circle one:
Medical Director Administrator Medical Director Administrator
Medical Staff Office Other Medical Staff Office Other
Specific Policy Limits will be printed on Certificate. Specific Policy Limits will be printed on Certificate.
Name of Certificate Holder Name of Certificate Holder
Street Address Street Address
City State Zip City State Zip
Please circle one: Please check one:
Medical Director Administrator Medical Director Administrator
Medical Staff Office Other Medical Staff Office Other
Specific Policy Limits will be printed on Certificate. Specific Policy Limits will be printed on Certificate.
NOTE: All applicants must read and initial the following:
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 Initial Here _________
of the third degree.
I hereby declare that the above statements are true and that I have not knowingly suppressed or misstated any material facts and I agree that
this application shall be the basis of the contract with the Insurer. I agree to notify the Insurer, or its designee, if there is any future material
change in any answer to this application, including without limitation, any change in my professional specialty, affiliation, or working arrangement
with any other physician, firm, or professional association.
I UNDERSTAND THAT ANY MATERIAL MISREPRESENTATION OR OMISSION MADE BY ME ON THIS APPLICATION MAY ACT TO
RENDER ANY CONTRACT OF INSURANCE NULL AND WITHOUT EFFECT OR PROVIDE THE INSURER WITH THE RIGHT TO RESCIND
IT. BY MAKING THIS APPLICATION, I AM NOT RELYING UPON ANY ORAL OR WRITTEN REPRESENTATION THAT COVERAGE HAS OR
WILL BE EXTENDED TO ME OR THAT A POLICY OF INSURANCE WILL BE ISSUED.
I further understand and agree that I have no right to demand or expect coverage until the Insurer, or its designee, has: (1) received my
completed application; (2) offered me a premium quote; and (3) received, as a precondition to coverage, the premium due. In addition, I
understand that if I pay my premium by check, electronic transfer or money order, it shall not be considered received by the Insurer until it has
been honored by the bank.
I AGREE THAT IF I FAIL TO COMPLY WITH THESE TERMS I WILL HAVE NO COVERAGE FOR ANY CLAIM UNDER ANY POLICY OF
INSURANCE FOR WHICH I AM APPLYING.
I also understand that the Insurer, or its designee, may wish to contact persons, hospitals, schools, employers, insurance agents, professional
liability insurers or other entities to verify and/or ascertain information regarding my credentials and background both prior to and if issued, after
the issuance of a contract of insurance. Therefore, I hereby instruct any such person, hospital, school, employer, insurance agent, professional
liability insurer or other entity to release to the Insurer, or its designee, any information regarding me, which the Insurer, or its designee, in good
faith, believes to be applicable and pertinent to this Application and if issued, the contract of insurance issued hereunder.
Date Signed:______________________________
Signature:_____________________________________________________________
Printed Name: _________________________________________________________
5
Claim Information Supplement (please print) Duplicate this page as required
1. Patient/Claimant
Name Age Sex
2. Date(s) of treatment and/or surgery which led to the allegations against you
3. Was suit ever filed? Yes No If “Yes”, state when /
Month Year
4. Name of insurance carrier defending you Policy No.
5. Names of other doctors and hospitals, if any, involved in claim or suit
6. Disposition or current status of claim or suit:
Open– Indicate case value established by carrier $
Closed–With no payment made Date
– Has carrier indicated desire to settle Closed–With payment made. Indicate amount of settlement or award: Yes No a. Your policy $ ____________ Date ________________
b. Total (if additional defendants involved) $
7. Narrative description of the medical facts: (must include, but not be limited to: nature of allegations in claim or suit; type of treatment and/or surgery). Use Additional Information Section at end of this Application if additional space is required.
1. Patient/Claimant
Name Age Sex
2. Date(s) of treatment and/or surgery which led to the allegations against you 3. Was suit ever filed? Yes No If “Yes”, state when /
Month Year
4. Name of insurance carrier defending you Policy No.
5. Names of other doctors and hospitals, if any, involved in claim or suit
6. Disposition or current status of claim or suit:
Open– Indicate case value established by carrier $
Closed–With no payment made Date
– Has carrier indicated desire to settle Closed–With payment made. Indicate amount of settlement or award: Yes No a. Your policy $ ___ _________ Date ____________
b. Total (if additional defendants involved) $____________________
7. Narrative description of the medical facts: (must include, but not be limited to: nature of allegations in claim or suit; type of treatment and/or surgery) (Use Additional Information section at the end this Application.)
