AXIS HEALTHCARE PROFESSIONAL LIABILITY
INSURANCE POLICY
PHYSICIANS & SURGEONS NEW BUSINESS APPLICATION
FOR CLAIMS-MADE PROFESSIONAL LIABILITY COVERAGE
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INSTRUCTIONS TO THE APPLICANT:
This application must be signed and dated by you within sixty (60) days of the desired effective date of coverage.
Any applicable Supplementary Applications, Claim Information Supplement(s) and additional documentation should
also be completed as needed.
If more space is required to answer a question, the response should be continued on your letterhead.
If a question is not applicable to you or your practice, state “N/A” to confirm it does not apply.
See the final page of this application for additional documentation that may be required.
Completion of this application does not bind coverage or obligate AXIS to provide you with a quote for coverage.
Incomplete applications cannot be processed. For any question where additional information will help to clarify
or complete your response, please attached an additional response on your letterhead.
General Information
1. Applicant Name:
Date of Birth:
Social Security No.:
Degree: MD DO DPM Other (describe):
National Provider Identifier (NPI #):
2. Mailing Address:
City, State, Zip:
County:
3. Applicant Type:
Individual
Corporation
Partnership
LLC
Employed Physician (list your employer):
Other (describe):
Practice Type:
Solo Practice
Group Practice
Entity Name:
Do you desire coverage for this entity?
Yes
How many other physicians work for this entity?
Applicant’s percentage of ownership:
Are other entities (including “doing business as” (d/b/a’s)) used? If “Yes,” list them below:
Yes
Do you desire coverage for these other entities?
N/A, no other entities exist
Yes
4. Primary Practice Location:
City, State, Zip:
County:
Hours of operation:
Number years at this location:
Do you have more than one practice location? If ”Yes,” please provide the following for each
Yes
location: location address, hours of operation & number of years at the location:
5. E-mail:
Office Phone:
Web Site:
Office Fax:
6. Residence Address:
Residence Phone:
City, State, Zip:
County:
Requested Coverage
1. Medical Specialty:
Sub-Specialty:
No Surg.
No Surg.
Minor Surg.
Minor Surg.
Surgery
Surgery
% of Practice:
% of Practice:
2. Effective Date:
Expiration Date:
Retroactive Date:
3. If you have claims-made coverage now, are you obtaining tail coverage from the current policy?
$200,000
$250,000
Requested Limits
$1,000,000
of Insurance:
$2,000,000
Other: $
HPL-651 (05-14)
/
/
/
/
$600,000
$750,000
$3,000,000
$4,000,000
Requested
Deductible:
No
%
No
No
No
%
%
Yes
No
None
$5,000
$7,500
$10,000
Other: $
Page 1 of 8
Medical Education & Training (or attach a current Curriculum Vitae and skip to Practice Information)
1. Month & year in which you began practicing medicine:
2.
Hospital / College
City and State
Completed
Dates From
Medical School
Yes
No
Internship
Yes
No
Residency
Yes
No
Add’l. Residency
Yes
No
Fellowship
Yes
No
3. Are you a U.S. citizen? If “No,” please explain:
Yes
4. Are you a Foreign Medical School Graduate? If “Yes,” please provide the date of ECFMG
Yes
certification:
5. Are you currently Board Certified? If “Yes,” please provide:
Yes
Name of Board:
Certificate Expiration Date:
6. Have you ever been denied Board certification or recertification or have you allowed your
Yes
certification to lapse? If “Yes,” state # of times and reason:
7. Please indicate the number of CME hours you have completed in the past two years:
/ To
No
No
No
No
Practice Information
1. List all States where you practice or have a medical license. (Use separate sheet if more space is needed.)
Medical License #
State
Expiration Date
% of practice in this state:
%
%
%
2. List your Narcotics/DEA License #:
Exp. Date:
Status:
3. List all hospitals where you have staff privileges. If none, please explain:
Hospital
City / State
County
% of Practice Type of Privileges
%
%
%
4. Within the last five (5) years, have your practice characteristics, procedures performed, or
Yes
No
business association(s) changed? If “Yes,” please describe:
5. List all office locations where you have practiced in the last ten (10) years. (Use separate sheet if more space is
needed.)
Street Address & City
6.
County
State
Dates From / To
Actions involving your practice:
Have your hospital privileges ever been suspended, restricted, denied, revoked, placed on
a.
probation or voluntarily surrendered to avoid sanctions? If “Yes,” please explain:
Has your board certification or membership in any medical society/association ever been
b.
refused, suspended, revoked or voluntarily surrendered? If “Yes,” please explain:
Has your medical license(s) or narcotics license ever been limited, suspended, revoked,
c. denied, voluntarily surrendered to avoid sanctions or investigated by any licensing board or
regulatory agency? If “Yes,” please explain:
Have you ever been diagnosed with or treated for alcoholism, drug addiction, chemical
d.
dependency, or a mental or chronic physical illness? If “Yes,” please explain:
Have you ever been charged with or convicted of a crime other than minor traffic violations?
e.
If “Yes,” please explain:
Have any complaints been registered against you with your medical association(s),
f.
hospital(s), or a state licensing authority? If “Yes,” please explain:
Have Medicare or Medicaid authorities ever investigated or brought charges against you? If
g.
“Yes,” please explain:
HPL-651 (05-14)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Page 2 of 8
Medical Procedures & Practice Data
1. Average Weekly Patient Encounters:
Average Number of Weekly Practice Hours:
2. Do you own, operate, administer, maintain a relationship with, or supervise any overnight bed
and board facility, urgent care facility, commercial laboratory, urgent care center, surgicenter,
Yes
No
abortion clinic, walk-in clinic, or birthing center? If “Yes,” please describe:
3. Are you the Medical Director of a healthcare facility? If “Yes,” please answer the following:
Yes
No
a. Do you desire coverage on this policy for your Medical Director duties?
Yes
No
b. If “Yes,” please list the facility name and number of hours per month you work there:
c. Coverage is requested for (check one):
Administrative Duties Only
Direct Patient Care
Both
4. Does your practice include the following? Check all that apply.
No Surgery - No surgery with the exception of: suture of minor lacerations, incision of boils and cysts, needle
aspiration of cysts (limited to subcutaneous tissue), incision and removal of foreign body from superficial or
subcutaneous tissue. Can involve localized treatment of second and third degree burns and umbilical and
urethral catheterization.
Minor Surgery - Applies to all general practitioners or specialists, except those performing major surgery or
anesthesiology, who may perform any of the following techniques or procedures:
 Colonoscopy, sigmoidoscopy, endoscopic procedures including endoscopic retrograde
cholangiopancreatography (ERCP),
 Pneumatic or mechanical esophageal dilation (not with bougie or olive),
 Angiography; Arteriography; Catheterization (arterial, cardiac or diagnostic),
 Needle biopsy – including lung, breast, prostate and superficial and subcutaneous tissue,
 Radiopaque Dye injection into blood vessels, lymphatics, sinus tracts or fistulae
Any procedure performed on a patient while under general anesthesia is considered Major Surgery.
Major Surgery - Involves operations in or upon any body cavity including, but not limited to, the cranium,
thorax, abdomen or pelvis, or any other operation that presents a distinct hazard to life because of the
condition of the patient or the length of the operation. It also includes removal of tumors (other than skin
tumors), liver/kidney/bone marrow biopsy, reduction of open bone fractures, amputations, abortions, removal
of any gland or organ, plastic surgery, tonsillectomies, adenoidectomies, cesarean sections or any other
operation using general anesthesia.
Gynecology / Obstetrics If checked, please indicate which procedures:
Office Gynecology only
Elective Abortions
Pre-natal care through 1st trimester only
Number each month:
Pre-natal care through 2nd trimester only
Maximum Gestation Age:
Pre-natal care full term
Where performed:
Amniocentesis
Therapeutic Abortions
High Risk Pregnancies
Number each month:
Dilation and Curettage
Maximum Gestation Age:
Cryosurgery
Where performed:
Obstetrics
Vaginal Deliveries:
Cesarean Sections:
VBAC Deliveries:
Indicate
annual # of: Non-Hospital Deliveries:
Describe circumstances:
Does a Midwife perform any deliveries or births? If “Yes,” what is the annual number
Yes
No
performed by a Midwife?
Radiology
Diagnostic
Therapeutic
Interventional
Annual number of reads performed:
Type of reads performed:
Do you perform reads for any patients residing in a State(s) other than your primary practice
Yes
No
State address? If “Yes,” complete the Teleradiology Supplemental Application.
Anesthesia / Office Surgery - Performance or assistance in any surgical procedure in your office or other
non-hospital setting during which anesthesia is administered by means other than a topical basis. Indicate
annual number and description of procedures:
Procedure
Number
Description of Procedures
General Anesthesia
Spinal or Caudal Anesthesia
Other
Anesthesia administered by:
Distance to nearest hospital:
Description of life saving equipment/supplies:
HPL-651 (05-14)
Page 3 of 8
5.
6.
7.
8.
9.
Pain Management - Check the procedures that you perform:
Blocks
Epidurals
Trigger Point Injections
Surgically Implanted Devices
Do you prescribe synthetic opiates? If “Yes,” please complete the following:
Yes
a. Number of prescriptions written:
b. Describe controls in place to reduce or eliminate drug-seeking behavior:
Elective Plastic Surgery - Describe procedures and annual number performed:
Alternative Medicine - Describe procedures and annual number performed:
Weight Control / Bariatrics - Complete the Bariatric Surgery Supplemental Application.
List procedures for weight reduction/control by other than diet and exercise:
Percentage of patients treated exclusively for weight control:
%
List injections used for weight control:
If you prescribe or dispense drugs for weight control, please list drugs and describe protocols:
Podiatry - Check the procedures that you perform:
Reduction of simple fractures of the heel or ankle
Reduction of compound factures of the heel or ankle
Use of lasers
Cutting or penetration of tissue other than that as defined as “No Surgery” above
Arthrodesis
Permanent removal of nail plate except by the use of electrical or chemical cautery
Surgical procedures of the ankle joint which includes any of the following:
 Tibia and/or fibula and their related structures
 Arthroplasty
 Grafts and/or implants
Surgical treatment of the muscles and tendons at the level of the ankle joint
Any other surgical procedures performed on the foot and/or ankle. Please describe:
Please check any procedures that you perform or check here to confirm you perform none of these.
None
Angiography
Hair Transplant Procedures
Arterial Catheterization
Hand Surgery
Arteriography
Human Chorionic Gonadotropin (HCG)
Assisting in surgery on patients other than yours
Laparoscopies
Assisting in surgery on your own patients
Liposuction Procedures
Bariatric Surgeries
MOHS Micrographic Surgery
Bio-Identical Hormone Replacement Therapy
Organ Transplants
Blepharoplasty
Orthopedic Surgery (Including Spinal Surgery)
Breast Implants, Augmentation or Reduction
Orthopedic Surgery (No Spinal Surgery)
Cardiac Catheterizations
Otoplasty
Chelation Therapy
Pedicle Screw Insertion
Chemical Peels
Pregnancy Care into Second Trimester
Cholecystectomies
Pregnancy Care into Third Trimester
Clinical Trials
Reconstructive Plastic Surgery
Closed Reduction of Fractures
Sex-Change/Gender Reassignment Procedures
Collagen Lip Injection
Sterilization Procedures
Colonoscopy
Thrombectomy of Arteries and Veins
Concierge Medicine (% of practice:
%)
Other, list:
Endoscopic Laser Therapy
Do you own or operate a Laboratory? If “Yes,” please answer the following:
Yes
a. Does the laboratory provide services solely for your patients?
Yes
b. If not limited to your patients, please explain:
Yes
Do you perform experimental or investigational procedures or prescribe/dispense experimental
Yes
drugs? If “Yes,” please explain:
Do you treat or supervise any provider who treats patients in any correctional setting?
Yes
If “Yes,” please list the facility name and answer the following:
a. Are you the Medical Director of this facility?
Yes
b. If “Yes,” do you desire coverage under this policy for your role as Medical Director?
Yes
c. Indicate the average number of hours you work in this setting each month:
Do you treat or supervise any provider who treats patients in any Nursing Home setting?
Yes
If “Yes,” please list the facility name and answer the following:
a. Are you the Medical Director of this facility?
Yes
b. If “Yes,” do you desire coverage under this policy for your role as Medical Director?
Yes
c. Indicate the average number of hours you work in this setting each month:
HPL-651 (05-14)
No
No
No
No
No
No
No
No
No
No
No
Page 4 of 8
10. Do you work in an Emergency Department? If “Yes,” please answer the following:
a. Is this solely to satisfy requirements for hospital privileges?
b. Indicate the average number of hours you work in the Emergency Department each month:
11. Are you a sports team physician or health care provider for a sports team?
If “Yes,” check all that apply:
High School
College
Professional
Other:
a.
Name and location of team(s):
12. Do you engage in telemedicine activity? If “Yes,” please answer the following:
a. Are you licensed in all states where patients who are treated via telemedicine reside?
b. If “No,” please explain:
c. Do you treat any patients who reside outside the U.S.?
d. If “Yes,” please list country(ies) where patients reside:
13. Do you prescribe drugs or provide diagnosis via the Internet? If “Yes,” please describe:
14. Do you endorse any products or participate in any activity which offers professional advice to the
public (e.g. newspaper columns, broadcasts, etc.)? If “Yes,” please describe:
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
Office Staff
1. Do you employ or contract with any physician(s) or surgeon(s)? If “Yes,” enter information below
Yes
No
and attach a current certificate of insurance for each if they are insured elsewhere.
Employee (E) or
Physician/Surgeon Name
Medical Specialty
Limits of Insurance
Liability Insurer
Contractor (C)
E
C
E
C
2. Do you employ, contract with, or supervise any of the following providers? If “Yes,” enter
Yes
No
information below:
Type
# Employed &
Contracted
Nurse Practitioner
Physician Assistant
CRNA
Nurse Midwife
Surgeon Assistant
Optometrist
Other (Please provide detail):
# That are only
Supervised
Type
# Employed &
Contracted
# That are only
Supervised
Medical Assistant
Medical Lab Tech.
Pharmacist
Nurse (RN/LPN)
X-Ray Technician
Physical Therapist
Insurance History
1. Please provide the following information pertaining to your past 5 years of professional liability coverage:
Insurance Carrier
Policy Period
Retroactive Date Limits of Insurance
Deductible
Premium
$
$
$
$
$
2. Have you ever practiced without professional liability insurance?
Yes
If “Yes,” specify dates and reason:
3. Have you ever had any insurance company decline, cancel, rescind or non-renew your
Yes
Professional Liability Insurance Policy? If “Yes,” please provide details:
4. Are you aware of any of the following:
a. Known claims which have not been reported to a prior insurance carrier?
Yes
A specific act, error, omission or circumstance involving professional services that may result
b.
Yes
in a claim which has not been reported to a prior insurance carrier?
Any request for medical records by a patient or his/her attorney that might result in a claim
c.
Yes
which has not been reported to a prior insurance carrier?
Information relating to service(s) on a Board that might result in a claim which has not been
d.
Yes
reported to a prior insurance carrier?
Any prior professional liability carrier refusing coverage for, or declining to accept a report of
e. a specific act, error, omission or circumstance involving professional services which may
Yes
result in a claim?
Any involvement, now or ever, in any Professional Liability claim or suit? If “Yes,” a
f.
Yes
Supplemental Claim Information Form must be completed for each claim.
If “Yes” to any of the above, please provide details:
HPL-651 (05-14)
No
No
No
No
No
No
No
No
Page 5 of 8
Authorization & Signature
I have answered the questions in this application to the best of my ability and declare, to the best of my knowledge, that
statements set forth herein are true and correct. My signing of this 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:
1. A change in specialty or medical procedures performed;
2. A change in location of practice, including exposures generated through telemedicine or out-of-state/out-of-country
patients;
3. Investigation, restriction, suspension or surrender of any state, medical or DEA license or hospital privileges;
4. Any physical or mental condition, illness or defect, including treatment for alcohol or substance abuse not previously
disclosed to the Company in writing;
5. Conviction, pleas or agreement related to any charges of a misdemeanor or felony (including DUI or DWI) other
than minor traffic offenses.
IMPORTANT NOTICE: Failure to report any claim made against you during your current policy term, or facts,
circumstances or events which may give rise to a claim against you to your current insurance company BEFORE
expiration of your current policy term may create a lack of coverage.
Alabama Fraud Statement
“Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or
confinement in prison or any combination thereof.”
Arkansas, Louisiana, Rhode Island, and West Virginia Fraud Statement
“Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.”
Colorado Fraud Statement
“It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting
to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado division of insurance within the department of regulatory agencies.”
District of Columbia Fraud Statement
“Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer
or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
false information materially related to a claim was provided by the applicant.”
Florida Fraud Statement
“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 of the third degree.”
Kentucky Fraud Statement
“Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information, or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime.”
Maine Fraud Statement
“It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.”
Maryland Fraud Statement
"Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison."
New Jersey Fraud Statement
“Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.”
HPL-651 (05-14)
Page 6 of 8
New Mexico Fraud Statement
“Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal
penalties.”
Ohio Fraud Statement
“Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.”
Oklahoma Fraud Statement
“WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.”
Oregon Fraud Statement
“Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
materially false information in an application for insurance may be guilty of a crime and may be subject to fines and
confinement in prison.
In order for us to deny a claim on the basis of misstatements, misrepresentations, omissions or concealments on your
part, we must show that:
A. The misinformation is material to the content of the policy;
B. We relied upon the misinformation; and
C. The information was either:
1. Material to the risk assumed by us; or
2. Provided fraudulently.
For remedies other than the denial of a claim, misstatements, misrepresentations, omissions or concealments on your
part must either be fraudulent or material to our interests.
With regard to fire insurance, in order to trigger the right to remedy, material misrepresentations must be willful or
intentional.
Misstatements, misrepresentations, omissions or concealments on your part are not fraudulent unless they are made
with the intent to knowingly defraud.”
Pennsylvania Fraud Statement
“Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.”
Tennessee, Virginia and Washington Fraud Statement
“It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.”
COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT’S ACCEPTANCE OF COMPANY’S
QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE. IT IS AGREED THAT THIS
FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL ATTACH TO THE
POLICY.
The applicant must sign this Application within sixty (60) days prior to the policy inception date.
This application is for insurance to be placed on a surplus lines basis with AXIS Surplus Insurance Company.
The following information is also required as part of your application to AXIS Healthcare:
 A copy of your current professional liability insurance Declarations page
 A copy of your Curriculum Vitae
 Copies of all advertising that you use
 A copy of your business letterhead
 Company loss runs, valued within the last 90 days
Applicant’s Signature
HPL-651 (05-14)
Print Name & Title
Date
Page 7 of 8
Supplemental Claim Information Form
A copy of this completed and signed supplement is required for all claims involving the applicant. Copies should
be made as needed.
Claim Basics
Applicant Name:
Claimant Information:
Initials:
Date of Alleged Incident:
Additional Defendant(s):
None
Insurer to Whom Claim was Reported:
Claim Status
Dismissed with Prejudice
Defense Verdict
Plaintiff Verdict
Settlement
Open
Age:
Date Claims was Made:
List:
Gender:
M
F
Dismissed without Prejudice
Total Award: $
Total Award: $
Amount of Reserve: $
Amount Paid on Your Behalf: $
Amount Paid on Your Behalf: $
Amount of Plaintiff’s Demand: $
Claim Description
Alleged act(s) on which the claim was based:
Description of the Claim:
Injury or Damage alleged to have been caused:
Other information (optional):
I attest that the above information is true and complete to the best of my knowledge, that this information becomes a part
of my application for coverage to AXIS, and that it is subject to the same conditions and warranty of my AXIS application.
Applicant’s Signature
HPL-651 (05-14)
Print Name & Title
Date
Page 8 of 8