Commercial Insurance Underwriters, Inc. A Surplus Lines Agency www.ciusgf.com 901 E. Saint Louis St. #205 Springfield, MO. 65806-2537
APPLICATION FOR PROFESSIONAL LIABILITY INSURANCE FOR ANESTHESIOLOGISTS
(CLAIMS MADE BASIS)
Applicant's Name
Agency Name
Address
Agent
Location
Email
Web Site Address
Phone
APPLICANT'S INSTRUCTIONS:
1. If you have a Curriculum Vitae, please attach to application and you do NOT have to complete Sections 7-9.
2. Please type in your answers.
3. If space is insufficient to answer any questions fully, send us a separate sheet.
4. Application must be signed and dated.
1. APPLICANT INFORMATION
a.
(i)
Full name of Individual Applicant: (include professional degree)
Degree
(ii)
Date of Birth Place of Birth
(iii)
Are you a U.S. citizen? No Yes
If "No", please indicate your status and date of entry into USA:
b.
Principal business premise address:
(Street)
(County)
(City)
(State)
(Zip)
Phone:
Other Office address:
c.
Your practice:
Solo Practitioner (unincorporated)
Professional Association
Solo Practitioner (incorporated)
Partnership
Employee of
Professional Corporation
(Name)
Other (Describe)
d.
Number of Employees:
Full time
Part time
Total
e.
If you practice other than as an employee OR an unincorporated solo practitioner:
List the names of ALL your partners, employees and members of your professional association/corporation who practice medicine:
Formal corporate, association, partnership or business name:
Please attach a copy of your letterhead.
f.
Limits of Liability desired: $ each claim $ aggregate
(Limits in policy will govern coverage)
g.
Is the Applicant a "Covered Entity" under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule? No Yes
Has the Applicant implemented procedures to comply with the HIPAA Privacy Rule?................................................................ No Yes
Provide the name and title of the Applicant's Privacy Officer.
Our Business Associate Agreement is available at www.shand.com or by fax by calling (847) 572-6268 (Form No. ZZ50002). This
is the only Business Associate Agreement we will recognize.
2. APPLICANT PRACTICE
Please list all states where you are licensed to practice:
i. Permanent
Temporary
ii. Permanent
Please list hospitals at which you are currently a staff member and show % of work at each hospital.
1.
%
2.
3.
Are you chief or head of the department? No Yes
If "Yes," indicate location #:
Please give the approximate percentages of your practice dedicated to the following specialties. Where applicable, indicate
the split between general and local anesthesia.
General
Local
Pediatric
Intensive Care Mgmt.
OB
Neuro
Vascular
Blocks/Eqidurals
Open Heart
Do You practice in a surgicenter or other non-hospital facility where general anesthesia is administered?............................................ No Yes
If "Yes," please provide details:
Do you limit your practice to anesthesiology?.................................................................................................................................... No Yes
If "No," indicate your other specialty and provide details:
Average patient load: Pts. Weekly Total Pts. Annually
Average number of hours practice time: Hrs. Weekly
3. APPLICANT PROCEDURES
Do you perform acupuncture anesthesia?
No Yes
During all anesthesia, do you use a pulse oximeter monitor?
If "No," please explain:
During all anesthetics:
Is an electrocardiogram continuously displayed?
How often is arterial blood pressure determined and evaluated? Every Minutes.
How often is heart rate determined and evaluated? Every Minutes.
(iv)
How is circulatory function evaluated?
During all general anesthesia, do you use an end tidal CO2 monitor?
During all general anesthesia using an anesthesia machine, do you:
Use an oxygen analyzer with a low concentration limit alarm?
Test proper functioning alarm prior to each use?
When ventilation is controlled by a mechanical ventilator, do you:
Use a device equipped with a full set of safety alarms?
If "No," explain:
Test proper functioning alarms prior to each use?
Are you present in the operating room throughout the conduct of all general anesthetics, regional anesthetics
and monitored anesthesia care?
4. PERSONNEL
List number and type of professional employees: (If none, state NONE.)
Physicians (other than yourself)
Nurse Anesthetists
Other (describe)
Describe Other:
Are all the above individuals licensed in accordance with the applicable state and federal regulations?
Do you supervise any individuals who are not your own employees?
If "Yes," please provide details and number of non-employed individuals supervised:
5. APPLICANT HISTORY ATTACH DETAILED EXPLANATION FOR ANY "YES" ANSWERS:
Have you or any of the employees, as shown in 4a. above:
Ever been the subject of investigative or disciplinary proceedings or reprimand by a governmental
(i) No Yes
or administrative agency, hospital or professional association?
Ever been convicted of an act committed in violation of any law or ordinance other than traffic offense?
(ii) No Yes
Ever been treated for alcoholism or drug addiction or undergone personal psychiatric treatment?
(iii) No Yes
Ever had any state professional license or license to prescribe or dispense narcotics refused, suspended, revoked,
(iv) No Yes
renewal refused or accepted only on special terms or ever voluntarily surrendered same?
(v)
Ever had any insurance company or Lloyd's cancel, decline, refuse to renew or accept only on special terms
(v) No Yes
their professional liability insurance?
(vi)
Ever failed any medical licensing or specialty organization examination?
(vi) No Yes
(vii)
Do you have any chronic physical illness or defect?
(vii) No Yes
Please list prior professional liability insurance carried for each of the past four years. IF NONE, STATE NONE.
Insurance Carrier
Limits of
Liability
Inception Exp.
Mo./Day/Yr.
Expiration
Was this a Claims
Made Policy Form?
If prior professional liability insurance was on a claims made basis, indicate retroactive exclusion date of coverage.
6. CLAIMS
Has any claim or suit for alleged malpractice been brought against you? If "Yes," please complete
Supplemental Claim Information form for each claim or suit.
Has any judgment been rendered against you or any monetary settlement made by you, or on your
behalf by any insurance carrier, from an incident alleging malpractice? If "Yes," please complete
Supplemental Claim form for each incident.
Are you aware of any acts, errors, or omissions or circumstances which may result in a malpractice claim
or suit being made or brought against you?
If "Yes," please complete Supplemental Claim Information form.
7. EDUCATION
From what medical school did you graduate?
Degree:
Year:
Location of School:
(Country)
If foreign medical student graduate, are you certified by Educational Council for Medical School Graduates?
If "Yes," state year and describe:
Have you had any additional Medical Training? No Yes If "Yes," complete the following:
From
To
Type
Are you American Board certified? No Yes Specialty:
If not, are you working toward Board Certification? For how long?
8. EXPERIENCE
Where have you practiced your profession since completion of training (include all "moonlighting" while in residence/fellowship, military
or any public service organization):
Prior Experience -
Location:
Practice Activity:
9. PROFESSIONAL SOCIETIES
Indicate membership in professional societies:
American Board in Medical Specialties: Prior Experience -
Special Medical Societies:
Specialty Colleges:
County Medical and Others:
* NOTICE TO APPLICANT: The coverage applied for is SOLELY AS STATED IN THE POLICY, which provides coverage on a "CLAIMS MADE" basis for ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD unless the extended reporting period option is exercised in accordance with the terms of the policy.
Any person who knowingly defrauds any insurance company by filing an application for insurance containing any false information or concealing, for the purpose of misleading, information concerning any fact thereto commits a fraudulent insurance act, which is subject to criminal and civil penalties.
WARRANTY: I warrant to the Insurer, that I understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the insurer evidence its acceptance of this application by issuance of a policy. I authorize the release of claim information from any prior insurer to Shand Morahan & Company, Inc., Ten Parkway North, Deerfield, Illinois 60015.
_________________________________________________
Name of Applicant
Title (Officer, partner, etc.)
Signature of Applicant
Date
SIGNING this application does not bind the Applicant or the Insurer or the Underwriting Manager to complete the insurance, but one copy of this application will be attached to the policy, if issued.
BROKER RISK SUMMARY
(Medical Malpractice and Specified Medical)
ACCOUNT NAME:
City, State, Zip
States of Licensure
New or Renewal for Shand
DESCRIPTION OF SERVICES: (Include management experience & staffing)
CURRENT INSURANCE PROGRAM:
Name of Carrier:
Limits:
Deductible:
Premium:
Expiration Date:
Retro Date:
LOSS EXPERIENCE: (7-10 years currently valued loss information)
RISK MANAGEMENT/QUALITY ASSURANCE PROGRAM: (Including Credentialing/hiring protocols)
DATE QUOTE NEEDED:
TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
2. Hit this Submit button.
