Medical Malpractice Application Medical Malpractice Application 1 GENERAL / EDUCATION2PROFESSIONAL3HISTORY4PRIOR INSURANCE / LOCATIONS5CLAIMS HISTORY6CLAIMS MADE COVERAGE Applicant's Last NameApplicant's Last Name* First Last M.I. Applicant's Date of Birth DD slash MM slash YYYY Current Medical License State(s)* Current Medical License Number(s) Phone*Email* Address Street Address City State / Province / Region ZIP / Postal Code EDUCATION AND TRAININGName and location of Medical / Dental School Granting Degree: City State: Year Graduated:If Applicant is a graduate of a non-US medical school, have they obtained an ECFMG Certificate? Yes No Independent memberships and professional societies:Is Application American Board Certified? Yes No Medical SpecialtyDate CertifiedMedical Specialty PROFESSIONAL SERVICES PROVIDEDType of Practice / Services: ** Addiction Medicine Dentist Family Medicine Geriatrics Internal Medicine Medical Director OB/GYN Optometrist Primary Care Psychiatry Surgery Other: Alternative / Unconventional Medicine (not mainstream), if applicable, please describe: Type of Practice / Services: * Type of Practice / Services: * Status:* Employed Contracted Volunteer Hours of Practice on behalf of the Applicant’s Employer or Named Insured: FULL TIME ( ≤ 20 hours per week) Professional Services rendered on behalf of Applicant’s Employer or Named Insured. PART TIME ( ≥ 20 hours per week) Professional Services rendered on behalf of Applicant’s Employer or Named Insured. Please specify the exact # of hours rendered on behalf of the Applicant’s Employer or Named Insured: # hoursDoes the Applicant’s practice include telemedicine activities, e.g., the transfer of data through electronic (video or computer) means in order to provide healthcare to patients who are geographically separated from the clinicians involved? Yes No What is the percent of the Applicant’s total practice time devoted to this activity? %Please explain the exact type of telemedicine.Is telemedicine done outside the U.S. territories? Yes No Does the Applicant obtain an informed consent, whether signed by patient or guardian before prescribing controlled substances? Yes No Does the Applicant create and maintain medical records for each patient under their care? Yes No If no, explain: Does the Applicant participate in a compensation fund or other similar program of state sponsored liability insurance? (Example: MCARE in Pennsylvania) Yes No INSURANCE AND PROFESSIONAL HISTORYHas the Applicant ever been denied professional liability insurance coverage? Yes No If yes, explain:Has the Applicant’s professional liability insurance coverage ever been cancelled or refused renewal? Yes No If yes, explain:Has the Applicant’s application (new or renewal) for professional liability insurance coverage ever been accepted subject to any conditions or restrictions? Yes No If yes, explain:Has the Applicant’s license ever been suspended or revoked? Yes No If yes, explain:Has the Applicant ever been convicted of a crime? Yes No If yes, explain: PRIOR INSURANCEPRIOR INSURANCEInsurance CarrierPolicy PeriodLimits of LiabilityCoverage Type* List Applicant’s insurers or Applicant’s employers’ insurers the past (3) years. Attach additional pages as needed. *(Occurrence / Claims Made)PRACTICE LOCATIONSPRACTICE LOCATIONSInsured’s Practice LocationAddressAddressTo (MM/YY) Current Practice location on behalf of the Applicant’s Employer or Named Insured: CLAIMS HISTORYIMPORTANT: This section must be completed in its entirety. Any malpractice claims or suits in which Applicant has been involved in during the past seven (7) years must be reported. Any incidents or circumstances of which the Applicant is aware of that are likely to give rise to a claim must be reported. Provide copies of suit papers or claimant letters. If the claim is closed, provide copies of settlement or judgment documents or order of dismissal. If reporting more than one incident, suit or claim, photocopy this form for each. Untitled N/A Has the Applicant ever had any malpractice claim(s) or suit(s) brought against them? If yes, explain:Is the Applicant aware of any circumstances, which may result in a malpractice claim or suit?Name of patient:Allegation/incident description:Incident date:Report date: If yes, explain: CLAIMS MADE COVERAGENotice: This section is being completed as an application for a Claims-Made policy. Only claims which are first made against the Applicant and reported to us during the policy period or Extended Reporting Period will be covered, subject to policy provisions. Various provisions in the policy restrict coverage. Read the entire policy carefully to determine the Applicant’s rights, duties and what is and is not covered. Additional Notice: If Claims Made coverage is provided, it should be clearly understood that the applicable retro date will be the latter of the medical professional’s date of hire or the date that the medical professional coverage is added to the Named Insured’s policy. Untitled N/A Policy Effective Date:* DD slash MM slash YYYY Policy Retroactive Date:* DD slash MM slash YYYY Line of Business: Within the past 5 (five) years has the Applicant given written notice under the provisions of any current or prior policy providing similar insurance of any claim or of any specific facts or circumstances which might give rise to a claim being made against the Applicant? Yes No If yes, explain:With respect to the coverages applied for, upon inquiry of any of person qualifying as a Named Insured under the proposed policy, are there any facts, circumstances, or situations which might give rise to a claim under the coverage(s) for which the Applicant is applying? Yes No If yes, explain:Additional Notes:
