560 Davis Street, Suite 200
San Francisco, CA 94111
APPLICATION FOR MEDICAL PROFESSIONAL LIABILITY INSURANCE
PHYSICIANS, SURGEONS, DENTISTS, AND PODIATRISTS
This application is for claims-made or occurrence coverage. It is subject to review and acceptance by The Company and does not
bind coverage. Additional information may be requested by The Company.
REQUESTING ADDITION TO A CURRENT NORCAL MUTUAL POLICY
If accepted, coverage will be extended only while you are acting within the course and scope of your duties for the group and will
be subject to the terms, conditions, and limitations of the policy. A copy of the policy will be made available to you upon request.
Please complete the entire application, sign, and date. Indicate not applicable (n/a) where appropriate.
Section 1: GENERAL INFORMATION
SECTION II: COVERAGE INFORMATION
Please provide a copy of your current Declarations page from your most recent Insurance Carrier, as well as copies of any
extended reporting endorsements (tails) that you may have purchased.
List all previous medical professional liability insurance you have had for the past 5 years, beginning with the most current.
SECTION III: SPECIALTY AND PRACTICE INFORMATION
Do you perform or provide any of the following services as a part of your practice?
If so, please describe.
Medical Specialties Change?
SECTION IV: EDUCATION AND TRAINING
Please describe your medical professional education and training
SECTION V: ENTITY/ORGANIZATION INFORMATION
Please provide the following:
Please provide the coverage information below for all health care providers you employ, contract or otherwise associate with,
for which coverage is NOT desired or attach a copy of their current Declarations page or Certificate of Insurance.
SECTION VI: CLAIMS INFORMATION
Complete the following and a claim/suit/incident supplemental form for each claim, suit, or incident and provide loss runs
for the past 10 years, or since the date you began practicing medicine if you began within the past 10 years.
SECTION VII: ADDITIONAL INFORMATION
For each question below that you answer “Yes,” please provide a complete explanation in the Remarks Section.
SECTION VIII: MISCELLANEOUS
NOTICE FOR NEW JERSEY APPLICANTS
AGREEMENTS AND NOTICES
I understand that any claims whose circumstances were known before the effective date of coverage are specifically excluded
from coverage under any policy of insurance that may be issued by NORCAL Mutual (The Company).
I understand that the NORCAL Mutual policy requires any disputes arising from it to be submitted to binding arbitration unless
specifically prohibited by applicable law.
I understand that, as a condition precedent to approval for coverage, The Company may perform a detailed inquiry and
investigation of the applicant’s background, competence, and qualifications. I hereby expressly consent to any such inquiry
and investigation through the use of any means legally available to The Company and its duly authorized agents and
representatives. I further expressly authorize all individuals and entities to whom such legal inquiry is made by The Company
and its duly authorized agents and representatives to provide the same with all information within their possession or under
their control that pertains to the applicant’s background, competence, and qualifications. I expressly release and discharge
the aforesaid entities and individuals and their agents and representatives from any and all liability that might otherwise be
incurred as a result of acts performed in connection with any inquiry or investigation, as well as in the evaluation of information
so received from whatever source.
All information requested in this application is considered material and important. I represent the truth of my statements and
information mentioned herein, and that I have not intentionally withheld any information that could influence the judgment of The
Company in considering this application for insurance. I understand that any material misrepresentation in this application that
The Company relies on to its detriment could void coverage. I understand that this application and any supplemental information
supplied by me or on my behalf is incorporated into and made a part of any policy of insurance that may be issued to me by
I understand that I must notify The Company immediately, in writing, if there are any changes from what I have previously
described in any information supplied by me or on my behalf and that The Company may withdraw or modify any outstanding
quotations or authorization or agreement to bind insurance.
I understand that this application is subject to acceptance by The Company and does not bind coverage.
New Jersey Applicants:
Fraud Warning: Any person who includes any false or misleading information on an application for an insurance policy is subject
to criminal and civil penalties.
Pollution Exclusion: The policy for which you are applying contains an absolute pollution exclusion that excludes coverage for any
claims and other events arising out of any pollution incident.
CLAIM | SUIT | INCIDENT SUPPLEMENTAL FORM
Attach a detailed narrative, which includes at least the information requested below, or complete this form, for each claim, suit,
or incident within the past 10 years. Provide adequate detail to allow proper evaluation. Additional information may be requested.