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PHYSICIANS AND SURGEONS PROFESSIONAL LIABILITY APPLICATION

(CLAIMS MADE COVERAGE)

1) Full Name of Applicant:

2) Principal Office Address:

County:

3) Home Address:

4) Social Security Number: DEA Number:

5) List the States and license numbers where you practice:

6) Date of Birth: Place of Birth:

7) Are you a U.S. citizen? Yes No

If no, indicate your status and date of entry into the United States:

8) What is your medical or surgical specialty?

What percentage of your practice is dedicated to this specialty? %

9) What is your subspecialty?

What percentage of your practice is dedicated to this subspecialty? %

10) Do you limit your practice to the above specialties? Yes No If no, what other specialties do you practice? Provide details:

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Yes No

%

Yes No

%

Yes No

Yes No

11) Does your practice include Pain Management?

If yes, specify the percentage of your practice derived from Prescription Only Pain Management.

12) Does your practice include prescribing of opioids?If yes, provide the following details:

a. Specify the percentage of your practice derived from opioid prescriptions

b. Do you full comply with the CDC Guideline for Prescribing Opioids?https://www.cdc.gov/drugoverdose/prescribing/guideline.html

c. Does your practice adhere to any and all prescription drug monitoring program (PDMP)

Do you also dispense the opioids? Yes No

13) Are you American Board Certified? Yes No

Medical Specialty: Date Certified:

Medical Specialty: Date Certified:

14) Type of Practice (check all that apply):

Individual Employee Member of Multi-person Corp or Association

Individual Corporation Partnership Other:

15) What is your total revenue?

$100,000 or less $100,001 - $250,000 $250,001 - $499,999 $500,000 or more

16) Please provide the names of all facilities that you practice at and your interest in each facility.

Name of Clinic or Facility and Location Interest (Owner, Partner or Employee)

*Attach a separate attachment if necessary.

17) Are you seeking coverage for your work at all of the above facilities? Yes No If no, list those facilities for which you do not require coverage and explain why coverageisn’t needed:

requirements in the state(s) where you conduct business?

d.

https://www.cdc.gov/drugoverdose/prescribing/guideline.html

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18) Please provide the number of professionals you employ or contract with and whether or not they carry their ownindividual medical malpractice coverage.

Employed Contracted Carry their own Med Mal policy*?

Physicians Yes No Physician Assistants Yes No Nurse Practitioners Yes No Surgical Assistants Yes No CRNA’s Yes No Chiropractors Yes No RN’s Yes No LPN’s, Nurse Aides Yes No Other: Yes No Other: Yes No

*Attach copies of declarations pages on above professionals that carry their own malpractice policies.

If you included any Physician Assistants or Nurse Practitioners above, please answer the following question:

Do you maintain practice agreements, delegation of service agreements, collaboration agreements or equivalent with such providers where/as required by state law? Yes No

19) Are all of the above individuals licensed in accordance with applicable state and federalregulations? Yes No If no, attach an explanation.

20) List the hospitals at which you are currently a staff member:

21) Briefly describe the type and extent of your hospital privileges:

22) Are you Chief or Head of a hospital department? Yes No If yes, which department(s):

23) Are you the medical director of a nursing home or assisted living facility? Yes No If yes, provide the name of the facility:

24) Are you the medical director of any other facilities? Yes No If yes, provide the names of each facility:

25) From what medical school did you graduate?

City, State and Country of medical school:

Degree: Year of Graduation:

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If foreign medical school graduate, are you certified by the Education Council for Medical School Graduates? Yes No

If yes, state the year:

26) Internship? Yes No If yes, complete the following:

Location: Dates From: To:

Type: Completed? Yes No

27) Residency? Yes No If yes, complete the following:

Location: Dates From: To:

Type: Completed? Yes No

Location: Dates From: To:

Type: Completed? Yes No

28) Where have you practiced your profession since completion of training:

In: From: To:

In: From: To:

In: From: To:

29) Additional medical training? Yes No If yes, provide details including type, location and date of training:

30) Have you participated in any continuing medical education program(s) within the past 5 years? Yes No If yes, provide details:

31) Indicate memberships in professional societies:

32) Do you perform one or more of the following?

A. Endoscopic procedures other than sigmoidoscopy or proctoscopy? Yes No If yes, describe:

B. Catheterization, other than swan-ganz, umbilical cord or urethral catheterization or arterial line in a peripheral vessel? Yes No If yes, describe:

C. Arteriography, lymphangiography, myelography or phenmoencephalography? Yes No

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D. Interventional radiology-percutaneous transluminal angioplasty or embolization? Yes No

E. Radiation therapy, including implants? Yes No If yes, describe:

F. Chemobrasion or dermabrasion? Yes No

G. Hair Transplants Yes No

H. Mhos micrographic surgery? Yes No If yes, describe:

I. Acupuncture? Yes No If yes, describe:

J. Prenatal care and normal deliveries? Yes No

If yes, do you perform home deliveries? Yes No

If yes, do you only perform prenatal care? Yes No

If yes, do you supervise nurse midwives? Yes No

When do you refer? week’s gestation.

K. Dilation and curettage? Yes No

L. Needle biopsies? Yes No If yes, describe:

M. Electroshock therapy or hypnosis? Yes No If yes, describe:

N. Radial keratotomy, excimer laser PRK, LASIK or any other surgical vision correction procedure? Yes No

O. Surgery other than incision of boils and superficial abscesses or suturing skin and superficial fascia? Yes No If yes, attach a list of all surgical procedures.

P. Non-spontaneous, induced abortions? Yes No

If yes, what is the maximum trimester?

Q. Vasectomies or reversal of vasectomies? Yes No

R. Hysterectomies? Yes No

If yes, do you perform laparoscopic hysterectomies? Yes No

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S. Cholecystectomies? Yes No

If yes, do you perform laparoscopic cholecystectomies? Yes No

If yes, how many performed as of this date?

T. Tonsillectomies and/or adenoidectomies? Yes No

U. Caesarian sections? Yes No

V. Spinal surgery? Yes No

If also chemonucleolysis, check here:

and/or percutaneous lumbar discectomy, check here:

W. Administration of general spinal or caudal block anesthesia? Yes No

X. Open reduction of fractures? Yes No

Y. Organ transplantation? Yes No If yes, describe:

Z. Sex change operations? Yes No

AA. Weight reduction surgery including gastric bypass or other stomach banding procedures? Yes No If yes, which procedures?

BB. Experimental research, surgical research or experimental therapy in human patients? Yes No If yes, describe:

CC. Cosmetic/plastic surgery? Yes No If yes, please complete the following:

Do you perform breast augmentation? Yes No

Do you perform breast reductions? Yes No

Do you perform liposuction? Yes No

If yes, what is the maximum amount of cc’s removed?

Do you perform fat recycling? Yes No

If yes, what parts of the body?

Do you use silicone implants? Yes No

If yes, which parts of the body?

Do you perform Botox injections? Yes No

If yes, in which parts of the body?

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DD. Penile lengthening or enhancement procedures? Yes No

EE. Do you perform pain management procedures? Yes No

If yes, please indicate the procedures you perform:

CATEGORY A:

Acupuncture Yes No

Botox Injections Yes No

Medication Only Yes No

Massage/Osteopathic Manipulation – No Anesthesia Yes No

Medical Marijuana – Prescription Only – No Dispensing Yes No

CATEGORY B:

Facet Joint Blocks Yes No

Lesioning Yes No

Percutaneous Discectomy Yes No

Percutaneous Endoscopic Nerve Root Decompression Yes No

Peripheral Nerve Block Yes No

Radio Frequency Nerve Ablation Yes No

Rapid Opiate Detoxification Yes No

Selective Nerve Root Block Yes No

Sympathetic Blocks Yes No

Trigger Point Injections Yes No

Schedule I or Schedule II Prescription Medications Yes No

CATEGORY C:

Dorsal Column Simulator Implants/Reprogramming Yes No

Epidural or Spinal Catheters Yes No

Intradiscal Electrothermal Therapy Yes No

Peripheral Nerve Stimulation Yes No

Spinal Infusion Implants/Pumps; Removal, Refilling/Reprogramming Yes No

Vertebroplasty Yes No

Discectomy Yes No

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FF. Any other surgical procedures not shown above? Yes No If yes, describe:

*PLEASE ATTACH LIST OF ALL SURGICAL PROCEDURES YOU PERFORM

33) Do you perform surgery in your office? Yes No If yes, list:

34) Do you perform surgery in other non-hospital facilities? Yes No If yes, what type of facility and list the surgical procedures:

35) In the course of surgery does a Board Certified Anesthesiologist provide the anesthesia? Yes No If no, provide details:

36) Do you do any hospital emergency room work? Yes No If yes, is the emergency room care:

Only for your own patients? Yes No

Required for staff privileges? Yes No

How many hours per month?

Does the hospital cover you for malpractice while you work in the emergency room? Yes No

Are you requesting coverage for your emergency room work? Yes No

37) Do you assist in surgery:

On your own patients? Yes No

On patients of others? Yes No

38) If your practice includes plastic surgery, specify the percentage of your practice devoted to:

Traumatic Surgery %

Cosmetic/Elective Surgery %

39) If your practice includes weight reductions/control (other than by diet and exercise), specify the percentage of patients that are exclusively weight control: %

Do you prescribe any weight control drugs? Yes No If yes, list drugs prescribed:

Do you dispense supplements for weight control? Yes No If yes, list supplements dispensed:

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Do you use injections for weight control? Yes No If yes, list the drugs injected:

40) Have you or any of your employees: (If yes, attach details.)

A. Ever been subject of investigation or disciplinary proceedings or reprimanded by a governmental or administrative agency, hospital or professional association? Yes No Attach a copy of Complaint and Consent Order document if applicable.

B. Ever been convicted for an act committed in violation of any law or ordinance other than traffic offenses? Yes No

C. Ever been treated for alcoholism or drug addiction or undergone personal psychiatric treatment or has any administrative agency, hospital or professional association requested or required you be evaluated for an alleged mental condition and/or alcohol or drug addiction? Yes No

D. Ever had any state professional license or license to prescribe or dispense narcotics refused, suspended, revoked, renewal refused or accepted only on special terms or ever voluntarily surrendered same? Yes No

E. Ever had any professional liability insurance cancelled, declined, refused to renew or accepted only on special terms? Yes No

F. Ever failed any medical licensing or specialty organization examination? Yes No

G. Do you have any chronic illnesses or defects? Yes No If yes, describe:

41) Do you supervise any individuals other than your own employees? Yes No If yes, provide a detailed explanation of your responsibilities, relationship and whether or not these individuals have their own medical malpractice coverage:

42) Are you under contract to any individual, firm or corporation other than your own? Yes No If yes, attach an explanation including details of responsibilities. If this contract contains a hold harmless agreement, attach a copy of the contract language.

43) Are you in the employ of, or under contract to any governmental entity? Yes No If yes, provide details and outline your duties:

44) Do you offer professional advice to the public such as through a website, radio or TV broadcasts, newsletters, etc.? Yes No If yes, provide details:

45) Do you advertise your professional services in any manner other than simple listing in a telephone directory? Yes No If yes, provide details and attach copies of all advertising brochures:

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46) Are you associated with any agency or organization that engages in any kind of advertising for, or solicitation of patients? Yes No If yes, provide details:

47) Average Weekly Patient Load:

Total Patients Annually:

Total Surgeries Performed Annually:

48) Average number of hours worked per week:

49) Do you anticipate any changes in your practice? Yes No If yes, describe:

50) List the prior medical malpractice insurance carried for each of the past 5 years beginning with the most current:

Company Policy Term Limits of Liability Retro Date Premium

*Attach a copy of the declarations page of your most recent policy.

51) Do you own, operate or provide professional services for, or at, any health care facility or business enterprise not already clearly described in this application? Yes No If yes, describe:

52) Has any claim or suit for alleged malpractice been brought against you? Yes No If yes, how many total claims or incidents?

If yes, complete the Supplemental Claim Information Form for each and every claim. Also, attach five years of currently valued company loss runs.

53) Has any claim or suit for alleged malpractice been made against you that has NOT been reported to a prior insurer? Yes No If yes, complete the Supplemental Claim Information Form for each and every claim.

54) Are you aware of any acts, errors, omissions or circumstances which may result in a malpractice claim or suit being made or brought against you? Yes No If yes, provide details including name of claimant, date of occurrence, date of first contact allegation and current status of incident:

Please attach the following information:

• CV or Resume • Five years of currently valued company loss runs • Copies of any disciplinary actions, stipulation orders or probation documents • Copies of declarations pages for all employees or contractors that carry their own med mal • Copy of applicant’s most current declarations page

https://www.admiralins.com/wp-content/uploads/2020/02/Supplemental-Claim-Information-Form-142APP0220.pdfhttps://www.admiralins.com/wp-content/uploads/2020/02/Supplemental-Claim-Information-Form-142APP0220.pdf

Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or 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. *Applies in MD only.

Applicable in CO: 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.

Applicable in FL and OK: 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)*. * Applies in FL only.

Applicable in KS: Any person who knowingly and with intent to defraud, presents, causes to be presented, or prepares with knowledge or belief that it will be presented, to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Applicable in KY, NY, OH and PA: 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 (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY only.

Applicable in ME, TN, VA, and WA: 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 and denial of insurance benefits. *Applies in ME only.

Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.

Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

Applicable in all other States: 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 material fact, commits a fraudulent insurance act, which is a crime and may also be subject to civil penalty.

I/We understand that this is an application for insurance only and that the completion and submission of this Application does not bind the Company to sell nor the applicant to purchase this insurance. I/We hereby declare that the above statements and particulars are true and I/we agree that this Application shall be the basis for any contract of insurance issued by the Company in response to it.

Electronic Signature of Applicant or Authorized Representative:

Title: Date:

If you prefer not to return the questionnaire with an electronic signature, please print and sign.

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Physicians and Surgeons Application [164APP0420].pdfApplication Fraud Statement

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