AXIS HEALTHCARE PROFESSIONAL LIABILITY
INSURANCE POLICY
HOSPITAL APPLICATION
(for surplus lines coverage)
AXIS SURPLUS INSURANCE COMPANY
Producer
Agency Name:
Producer Name:
Telephone:
E-Mail:
Applicant
Named Insured:
County:
Address:
City/State/Zip:
CEO:
Risk Manager:
Website: www.
Authorized representative for insurance matters:
Telephone:
Number of years the Applicant has been in operation:
Number of years the Applicant has been under present ownership:
Other Entities
List all owned (50% or more) entities to be considered as a Named Insured, or attach a separate list:
Name
Type/Purpose of Facility
Retroactive Date
Facility Information
Type (check all that apply)
Children’s Hospital
Clinic
Convalescent or Nursing Home
General Acute Care Hospital
Hospice
Psychiatric Hospital
Research Hospital
Surgical Center
Teaching Hospital
Ownership and Control
Governmental
Individual
Partnership
Corporation
Tax Status
For Profit
Not for Profit
Medicare Approved
The facility is (check all that apply):
Accredited by AOA*
Member of American Hospital Association
Accredited by JCAHO*
Member of State Hospital Association
*Date of last survey:
*Accreditation Period:
Details of Requested Coverage
Requested Effective Date:
Expiration Date:
Medicare Approved
Other (describe below):
Date Quote is Needed:
Requested Limits
Professional Liability
General Liability
Employee Benefits Admin. Liability
(EBL)
Excess Liability
Umbrella Liability
HPL-656 (05-14)
$
$
per claim
aggregate
$
$
per claim
aggregate
$
$
per claim
aggregate
$
$
per claim
aggregate
$
$
per claim
aggregate
Claims Made Retroactive Date:
Occurrence Coverage
Claims Made Retroactive Date:
Claims Made Retroactive Date:
Total number of employees:
Claims Made Retroactive Date:
Claims Made Retroactive Date:
Page 1 of 11
Deductible
None
Professional Liability
General Liability
Employee Benefits Admin. Liability
(EBL)
$
$
per claim
aggregate
$
$
per claim
aggregate
$
$
per claim
aggregate
Self-Insured Retention
None
Professional Liability
SIR applies to:
Professional
Is there an Insurance Trust?
$
$
per claim
aggregate
General
Yes
No
EBL
Is there an
Insurance Captive?
Applies to:
Indemnity Only or
Indemnity & Expense
Indemnity Only or
Indemnity & Expense
Indemnity Only or
Indemnity & Expense
Applies to:
Indemnity Only or
Indemnity & Expense
Other:
Yes
No
Who currently handles claims within the SIR?
Prior Insurance History
Complete the following professional liability insurance history:
Current carrier*:
Claims Made
Occurrence
Effective Date:
Expiration Date:
Retroactive Date:
Limits: $
/$
Deductible/SIR $
Expiring premium: $
Claims Made
1st prior carrier :
Occurrence
Effective Date:
Expiration Date:
Retroactive Date:
Claims Made
2nd prior carrier :
Occurrence
Effective Date:
Expiration Date:
Retroactive Date:
If you are currently insured on a claims-made policy, are you obtaining Extended Reporting Period
Yes
(“Tail”) Coverage from your current insurance carrier?
*attach copy of current policy
No
Note: To prevent possible gaps in your Claims-Made coverage, either Extended Reporting Period Coverage from your
current insurer or Prior Acts Coverage from AXIS must be purchased. Prior Acts Coverage is subject to underwriting
approval and may not be available to all applicants.
Census Data
BEDS
Occupancy: The daily average number of occupied beds shall be the sum of the annual occupancy divided by 365.
Acute Care Beds are defined as: All beds licensed by the state, including but not limited to, all beds designated for
burn, coronary, intensive care, medical, surgical, pediatrics, or other acute care patients.
Number of Licensed Beds
Average Annual Occupied Beds
Current Year
1st Prior
2nd Prior
Current Year
1st Prior
2nd Prior
Acute Care
Cribs & Bassinets
Psychiatric
Rehabilitation
Swing Beds
NURSING HOME BEDS
N/A (applicant has no nursing home beds)
Skilled Care
Intermediate Care
Residential Care
Independent Living
HPL-656 (05-14)
Page 2 of 11
Visits & Procedures
Emergency Medicine
Mental Health
Alcohol/Drug Rehabilitation
Physical Rehabilitation/Therapy
Home Health Care
Nursing Home Visits
Other Outpatient Visits (excluding Bariatric)
Inpatient Surgeries (excluding Bariatric)
Outpatient Surgeries
Bariatric Surgeries (Outpatient/Inpatient)
Total Deliveries (including C-sections)
Cesarean Sections (C-sections)
Vaginal Births after C-Section (VBACs)
Other exposures (specify):
Current annual visits
Projected annual visits
/
/
Personnel
List the number of each provider type:
NOTE: No individual coverage is afforded to specialties marked with an “*” unless specifically requested.
Provider Type
*Employed Physician
*Employed Resident
Nurse Anesthetist
Nurse Midwife
Nurse Practitioner
Physician Assistant
Podiatrist
Psychologist
Dentist
Employees
Independent Contractors
Have Separate Coverage
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
*If coverage is requested, individual applications may be required.
Services
None of these
Indicate if the Applicant presently provides or operates, or plans to provide or operate any of the following:
Abortion Clinic
Dental Services
Intensive Care Unit
Pediatrics
Ambulance Service *
Dialysis
Long-Term Care
Rehabilitation
Bariatric Surgery ‡
Emergency Room
Neonatal ICU
Research/Experimental Surg.
Birthing Suites
Fitness Center *
Nursery
Robotic Surgery
Blood Bank *
General Medicine
OB / GYN
Skilled Nursing
Teleradiology ‡
Cardiac Cath. Center
General Surgery
Oncology
Chemical Dependency
Geriatrics
Organ Transplants
Telemedicine (non radiology)
Concierge Medicine
HMO
Outpatient Surg.
Transplants
Coronary Care Unit
Home Health
Pain Management
Transportation Services
Day Care *
Hospice
Pathology
Trauma Centers
Other (describe):
‡ Supplemental application is required.
*Complete the following information for SERVICES selected above:
Ambulance Service
# of runs per year:
Employed EMTs/Paramedics?
If “Yes,” how many?
Blood Bank
Are you accredited by:
Hospital patients only
HPL-656 (05-14)
# of vehicles:
Yes
No
AABB
CAP
Used by outside patients
Fitness Center
On premises
Patient only
Day Care
Kids per day:
General public
Swimming pool
Caregiver/Child Ratio:
Page 3 of 11
Emergency Department
What is the JCAHO designation of the Emergency Department?
N/A
Level I (tertiary)
Level II (comprehensive)
Level III (basic)
Level IV (standby)
Level V
Emergency Department is staffed by (check all that apply):
Employed Physicians
Contract Group
Staff Physicians
If under contract, provide name of group:
Required Professional Liability limits: $
/$
Are all ER physicians required to be Board Certified or eligible in Emergency Medicine?
Yes
Are the ER physicians required to respond to cardiac/respiratory arrests or other medical Emergencies
Yes
occurring in the institution?
Is the Emergency Room equipped with the following:
a. Emergency resuscitation care equipped with defibrillator
Yes
b. Electrocardiograph machine
Yes
c. Staffed radiology room(s)
Yes
d. Dedicated triage area and staff
Yes
e. Dedicated trauma room(s) and staff
Yes
f. Dedicated laboratory personnel
Yes
Do any of the Emergency Department staff routinely work more than a eight (8) hour duty shift? If
Yes
“Yes,” explain:
Surgery
Are any of the following performed at your facility and/or outpatient surgicenters?
Procedure
Hospital Outpatient Center
Cosmetic Surgery
Experimental Surgery
Laser-Assisted Surgery / LASIK Surgery
Neurosurgery
Sex Change / Gender Reassignment Surgery
Weight Reduction / Bariatric Surgery
Pathology
Pathology Department is staffed by (check all that apply):
Employed Physicians
Contract Group
If under contract, provide name of group:
Required Professional Liability limits: $
/$
None
Not Performed
No
No
No
No
No
No
No
No
No
Annual # Done
Staff Physicians
Anesthesia
Anesthesiology Department is staffed by (check all that apply):
Employed Physicians
Contract Group
Staff Physicians
If under contract, provide name of group:
Required Professional Liability limits: $
/$
Are all anesthesiologists required to be Board Certified or eligible in Anesthesiology?
Yes
No
Do CRNA’s provide anesthesia services?
Yes
No
CRNA employment by:
Applicant
Anesthesiology
Surgeon
Independent Contractor
Is the anesthesia care performed by CRNA’s supervised and reviewed by the anesthesiologists? If
Yes
No
“No,” explain:
Radiology
Radiology Department is staffed by (check all that apply):
Employed Physicians
Contract Group
Staff Physicians
If under contract, provide name of group:
Required Professional Liability limits: $
/$
Are all radiologists required to be Board Certified in Radiology or Nuclear Medicine?
State the number of X-ray machines owned and/or operated:
How many are used for:
Diagnosis:
Treatment:
HPL-656 (05-14)
Yes
No
Both:
Page 4 of 11
Obstetrics
How many of each do you have?
Labor rooms
Delivery rooms
Birthing suites
Is the delivery room suite separate from the surgical suite?
Yes
No
What is the C-section rate for the previous 12-month period ?
Are you in current compliance with all ACOG standards, including those that pertain to C-sections?
Yes
No
Is an Obstetrician available in-house twenty-four (24) hours per day for the obstetrics suite? If “No,”
Yes
No
what is the maximum time allowed for arrival at the facility?
Is an Anesthesiologist or CRNA available in-house twenty-four (24) hours per day? If “No,” what is the
Yes
No
maximum time for arrival at the facility?
If the Applicant has a neonatal intensive care unit (NICU), what is the total number of neonates admitted in the last 12
months?
N/A (we do not have a NICU)
Is the Applicant a regional referral center for newborns requiring intensive care? If “Yes,” how many
Yes
No
were transferred from other facilities?
Is a full-time attending neonatologist on-site in the NICU twenty-four (24) hours per day?
Yes
No
Do providers other than Obstetricians (Family Practice with OB, CNMs, etc.) ever deliver babies in
Yes
No
your hospital? If “Yes,” explain:
Staff Credentialing & Privileges
Are credentials for all Physicians and Allied Professionals checked and approved prior to granting staff
privileges?
Are privileges probationary? What is the amount of probationary time?
Are new staff members proctored?
Are there any Physicians or Allied Professionals who are not licensed or who have restricted licenses
or privileges?
Are Physicians and Allied Professionals privileges reviewed at least once every other year?
Are all foreign medical graduates certified by the Educational Council for Foreign Medical Graduates
(ECFMG) or have they passed the FLEX?
Are independent Physicians and Allied Professionals required to maintain professional liability
insurance? What are the required limits? $
/$
Are certificates of insurance required as verification of insurance?
Risk Management
Is there an individual who is designated with the job title and role of Risk Manager? If “No,” explain:
Is there a written, formalized Risk Management plan? If “No,” explain:
Is this plan regularly reviewed for effectiveness and/or any necessary changes? If “Yes,” how often is
the plan reviewed?
Is there an ongoing Quality Assessment or Improvement plan? If “No,” explain:
Yes
No
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
No
Yes
No
Contractual Agreements
Identify any remaining contracted professional services performed at the hospital not previously identified
None (all have been previously identified)
Home Health
Occupational Therapy
Physical Therapy
Laboratory
Pharmacy
Respiratory Therapy
Other:
Does the applicant require contractors to provide verification of professional liability insurance? If
Yes
“Yes,” what limits are required? $
/$
Are all contracts reviewed by legal counsel prior to execution?
Yes
Does the applicant indemnify (hold harmless) any other party for liability? If “Yes,” submit a copy of
Yes
the agreement with this application.
Does the applicant rent or lease equipment to or from others?
Yes
Does the applicant contract outside entities for the removal and/or disposal of any of the following
wastes?
Yes
Low Level Radioactive
Other Radioactive
Hazardous or Toxic
Medical or Infectious
If “Yes” to any of the above, is evidence of insurance required? What are the minimum limits
Yes
required? $
Does the applicant have any on-site dumps, landfills, or other disposal areas?
Yes
HPL-656 (05-14)
No
No
No
No
No
No
No
Page 5 of 11
General Information
Does the applicant engage in any of the following:
a.
Formal clinical research under the auspices of an institutional review board?
b.
Administration of non-FDA approved pharmaceuticals (experimental drugs)?
c.
Biomedical device research and development?
d.
Animal research?
e.
Medical and/or surgical experimentation that is not approved by an IRB?
If “Yes” to any of the above, provide details:
Has the Applicant or other associated entity ever had its license revoked, suspended or placed on
probation by any licensing agency? If “Yes,” explain:
Has the Applicant ever been investigated by any third party for alleged fraud, erroneous billing or
entered into a Compliance Integrity Agreement? If “Yes,” explain:
Has the Applicant entered into any joint ventures or limited partnerships? If “Yes,” explain: (name of
venture, % of ownership & description)
Is any part of the Applicant operated/leased by a management corporation? If “Yes,” give the name of
the corporation, details of the structure and provide a copy of the contract:
Does the Applicant participate in any teaching programs or have affiliations with educational
institutions? If “Yes,” explain:
Does the Applicant anticipate any facility or service expansions within the next year? If “Yes,” explain:
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Does the Applicant anticipate any sale of assets, mergers, acquisitions, consolidation or change in
Yes
operations or services within the next twelve (12) months? If “Yes,” explain:
Provide a detailed explanation for the following questions answered “Yes”, on a separate sheet of paper:
Has any company ever declined, cancelled, refused to renew, restricted, or surcharged your
Yes
professional liability insurance?
Have there been any complaints or suits brought against the applicant by a member of its medical staff
Yes
or any other provider working in the facility?
Is the applicant aware of any conduct, circumstance, occurrence, incident, or accident that is likely to
or reasonably could be expected to give rise to a claim that has not yet been reported to the current
Yes
and/or prior insurance carrier?
Physical Premises
List all buildings the applicant owns, controls, or occupies or attach a separate list.
Construction
Year
# Of
Address
Use
(Brick, Fire
Built
Stories
Resistive etc.)
Does the Applicant own, rent, or charter any aircraft or helicopters?
Does the Applicant have or maintain a heliport/helipad?
a. If “Yes,” where is the pad located (e.g., parking lot, top of building etc.)
b. Is the area identified with warning signs and/or fencing?
c. Is the area equipped with proper lighting for night or foul weather landings?
d. How many annual landings do you have?
Does the Applicant own ambulances or other emergency vehicles?
Do all locations meet applicable National Fire Protection Agency (NFPA) building codes?
Total
Sq. Ft.
No
No
No
No
Complete
Sprinkler
System
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
No
Yes
Yes
No
No
Automobile Exposures
If the applicant owns, controls, or hires any automobiles, attach a copy of your business auto coverage if you desire
excess or umbrella coverage from AXIS for this exposure and complete the following:
Type of ownership
# of Private Passenger Autos
# of Multi-Passenger Autos
# of Ambulances
Owned
Non-owned or hired
HPL-656 (05-14)
Page 6 of 11
THE UNDERSIGNED AUTHORIZED OFFICER OF THE APPLICANT DECLARES THAT THE STATEMENTS SET
FORTH HEREIN ARE TRUE, AND AFFIRMS THAT IF THE INFORMATION SUPPLIED IN THIS APPLICATION
CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF INSURANCE, THE
UNDERSIGNED WILL IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY
WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENT TO BIND
INSURANCE. FURTHERMORE, THE UNDERSIGNED DECLARES THAT THE SIGNING OF THIS FORM DOES NOT
BIND COVERAGE NOR COMMIT TO ORDERING 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.”
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.”
HPL-656 (05-14)
Page 7 of 11
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.”
This application is for insurance to be placed on a surplus lines basis with AXIS Surplus Insurance Company.
Applicant’s Signature
Print Name & Title
Date
(must be signed by the President, CEO, Chairman,
Executive Director, CFO, COO or Risk Manager)
Attach copies of the following with this application:
Current Audited Financial Statement
Risk Management Plan
Current Professional Liability Policy
Medical Staff Bylaws
Current Loss Run(s) (valued within 60 days for the current year and a minimum of 5 additional years)
Agreements where other parties are indemnified
JCAHO or other Accreditation survey (JCAHO - Submit a copy of the most recent JCAHO Accreditation Letter,
Scoring Grid and Type 1 Recommendations and responses)
Business auto declarations page and loss runs (if excess/umbrella auto coverage desired)
HPL-656 (05-14)
Page 8 of 11
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:
Gender:
M
F
List:
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
Print Name & Title
Date
(must be signed by the President, CEO, Chairman,
Executive Director, CFO, COO or Risk Manager)
HPL-656 (05-14)
Page 9 of 11
Nursing Home Supplement
Applicant
Check this box to confirm all is the same here as it is for the hospital
Named Insured:
County:
Address:
City/State/Zip:
CEO:
Risk Manager:
Website: www.
Authorized representative for insurance matters:
Telephone:
Facility History
How long has the facility been in operation under your control?
Is the facility certified for Medicaid reimbursement? If “No,” explain:
Has the facility’s license ever been revoked? If “Yes,” explain:
Facility Type
Skilled Nursing Facility (24-hour nursing care services
are provided)
Intermediate Care Facility (medical, nursing, social &
rehabilitative services are provided)
Personal Care Facility (non-continuous nursing care with
supervised living care)
Other (describe):
years
Yes
No
Yes
No
months
Ownership
Corporate Ownership (100%) (list name of
corporate owner):
Joint Venture / Partnership (list all parties with
their % of ownership):
Individually owned (list name of individual
owner):
Other (describe):
Facility Services
Are all bedridden patients on the ground floor? If “No,” explain:
Yes
No
Are any of the following services contracted from outside the facility?
Yes
No
Dental
Dialysis
Grooming/Beauty
Inhalation Therapy
Physical Therapy
X-Ray
Other (describe):
Are Certificates of Insurance required from all contractors for outside services?
Yes
No
If “Yes,” what limits of insurance are required? $
Does the nursing home own or operate any of the following services?
Yes
No
Home Health Care Services
Durable medical Equipment Service
Adult Day Care
Wellness / Fitness Center Program
Pharmacy for patients only
Pharmacy for non-patients
Does the facility sponsor any recreational events involving residents and outsiders?
Yes
No
If “Yes,” describe:
What is your ratio of patients to nurses?
patients to
nurses
How many of each of the following employees do you have (if none, show 0)?
LPNs
RNs
Nurse Aides
Therapists
Pharmacist
Volunteers
Other (describe):
Do you have a transportation arrangement in place for patients requiring acute care?
If “Yes,” list the facility name and # of miles from your facility:
Is a physician appointed to act as the Medical Director of the facility
Yes
No
Do you credential all attending physicians treating patients in your facility?
Yes
No
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
Print Name & Title
Date
(must be signed by the President, CEO, Chairman,
Executive Director, CFO, COO or Risk Manager)
HPL-656 (05-14)
Page 10 of 11
AXIS Surplus Insurance Company
Professional Employee Roster
(make copies of this page as needed)
Last Name
First Name
PT?*
Specialty
NPI#**
Retroactive Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
*PT = part-time (check box for employees working 20 hours per week or less)
** National Provider Identifier number
HPL-656 (05-14)
Page 11 of 11