AXIS HEALTHCARE PROFESSIONAL LIABILITY
INSURANCE POLICY
Bariatric Surgery Supplemental Application
Basics
Applicant Name:
Date Applicant began Bariatric Procedures:
Number of Bariatric Procedures
In a Bariatric Center of Excellence:
Not in a Bariatric Center of Excellence:
Total Annual Bariatric Procedures:
Current Year
1st year prior
2nd year prior
3rd year prior
Practice Information
Are you certified by the American Society for Bariatric Surgeons?
Yes
No
Are you certified by the Society of American Gastrointestinal &
Yes
No
Endoscopic Surgeons?
Which of the following do you provide for your bariatric patients?
Nutrition Counseling
Respiratory Therapy
Mental Health
Other (describe):
Please provide the following about the bariatric patients your practice will accept:
Minimum Age:
Maximum Age:
Minimum BMI:
Other criteria (describe):
Procedures by Type
List the approximate number of procedures by type for your bariatric practice for this year and next year:
Annual Procedures - Current Year Annual Procedures – Projected
Type
Open
Laparoscopic
Open
Laparoscopic
Adjustable Gastric Banding
Biliopancreatic Division
Duodenal Switch
Gastric Balloon
Gastric Sleeve Gastrectomy
Roux-en-Y Gastric Bypass
Vertical Banded Gastroplasty
Other:
Totals:
Has the above breakdown by type changed by 25% or more since your
Yes
No
current retroactive date? If “Yes,” describe:
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-654 (05-14)
Print Name & Title
Date
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