NORCAL Form 2 Please fill out the form below: NORCAL Mutual Application APPLICATION FOR MEDICAL PROFESSIONAL LIABILITY INSURANCE PHYSICIANS, SURGEONS, DENTISTS, AND PODIATRISTS 560 Davis Street, Suite 200 San Francisco, CA 94111 p: 844.4NORCAL f: 877.686.0558 submissions@norcal-group.com norcalmutual.com APPLICATION FOR MEDICAL PROFESSIONAL LIABILITY INSURANCEPHYSICIANS, 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.Agency name Agency Location Producer name REQUESTING ADDITION TO A CURRENT NORCAL MUTUAL POLICYIf 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.Name of EntityOrganization or Physician(Required) Policy Number APPLICATION CHECKLISTPlease complete the entire application, sign, and date. Indicate not applicable (n/a) where appropriate.Answer all questioins fully and completelyAnswer all questions fully and completely. Alternatively, you may attach a credentialing application or application for another insurer that you have completed within the past 90 days and complete this application beginning with Section VI, Claims Information. Completed A copy of the Declarations page and endorsements…A copy of the Declarations page and endorsements from your most recent insurance policy. If an extended reporting endorsement (tail) has been purchased, please provide a copy as well. Completed Loss runs for the past 10 years…Loss runs for the past 10 years, or since the date you began practicing medicine if you began in the last 10 years. Completed A copy of your letterhead Completed A copy of your current Curriculum Vitae (CV). Completed If you are requesting coverageIf you are requesting coverage for a corporation, please include a completed Entity/Organization Application and the Articles of Incorporation. Completed If you employ, independently contract with, or otherwiseIf you employ, independently contract with, or otherwise maintain an association with other health care providers (including physicians and/or health care extenders) and desire coverage for them, a separate application is required for each provider. Completed Please download and print the NORCAL Mutual Business Associate AgreementPlease download and print the NORCAL Mutual Business Associate Agreement at http://www.norcalmutual.com/resources and file with your other HIPAA compliance documents. Revised regulations in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) amended the Privacy, Security, Enforcement and Breach Notification Rules, requiring NORCAL Mutual to enter into a revised Business Associate Agreement with all business associates who manage or distribute protected health information. Completed Section 1: GENERAL INFORMATIONFirst Name(Required) Middle Name(Required) Last Name(Required) Sex Male Female Physician Type(Required) MD DO DMD DDS DPM Date of Birth(Required) DEA License #(Required) FEIN License #(Required) Name of NORCAL Insured Entity/Organization/Physician Authorized Office RepresentativePhysician Title Physician Website Physician Email(Required) Enter Email Confirm Email Primary Office Phone Home Phone Cell Phone Fax Primary Office Address City State Zip Code Home Address City_2 State_2 Zip Code_2 Billing Address City_3 State_3 Zip Code_3 Other Address City_4 State_4 Zip Code_4 Preferred Mailing Address Primary Office Home Address Billing Address Other Address Medical LicensureState 1(Required) License1(Required) Expiration Date 1(Required) % of Practice 1(Required) Status of License Active Inactive Pending State 2 License2 ExpirationDate 2 % of Practice 2 Status of License 2 Active Inactive Pending State 3 License3 ExpirationDate_3 % of Practice_3 Status of License 3 Active Inactive Pending SECTION II: COVERAGE INFORMATIONCOVERAGE DESIRED 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.Coverage DesiredCOVERAGE DESIRED 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. Claims-made WITHOUT prior acts coverage. Under this option, the retroactive date will be the same as the effective date of coverage. Coverage for claims arising from an act or omission that occurred prior to the effective date of this policy will not be provided. Claims-made WITH prior acts coverage. Under this option, the retroactive date will be the same as the retroactive date on your current policy. Modified Claims-made (pre-paid tail) WITHOUT prior acts coverage. Under this option, the retroactive date will be the same as the effective date of coverage. Coverage for claims arising from an act or omission that occurred prior to the effective date of this policy will not be provided. Occurrence coverage. Requested Effective Date mmddyyyy Retroactive Date mmddyyyy Limit Amount LimitType Shared Separate Will your also carry insurance with another company? Yes No Coverage HistoryList all previous medical professional liability insurance you have had for the past 5 years, beginning with the most current.Coverage_Period: From(Required) Coverage_Period: To (mm/dd/yyyy)(Required) Insurer1(Required) CoverageHistory-CoverageType(Required) Occurrence Claims-made Coverage_Type: Retro Limit_Amount: Amount(Required) CoverageHistory-Limit_Amount(Required) Shared Separate CoverageHistory_Premium(Required) Coverage History: Tail Purchased 1 Yes Coverage_Period: From (mm/dd/yyyy)_2 Coverage_Period: To (mm/dd/yyyy)_2 InsurerFrom To_2 CoverageHistory-CoverageType_2 Occurrence Claims-made Coverage_Type: Retro_2 Limit_Amount: Amount_2 CoverageHistory-Limit_Amount_2 Shared Separate CoverageHistory_Premium_2 Coverage History: Tail Purchased 2 Yes Coverage_Period: From (mm/dd/yyyy)_3 Coverage_Period: To (mm/dd/yyyy)_3 InsurerFrom To_3 CoverageHistory-CoverageType_3 Occurrence Claims-made Coverage_Type: Retro_3 Limit_Amount: Amount_3 CoverageHistory-Limit_Amount_3 Shared Separate CoverageHistory_Premium_3 Coverage History: Tail Purchased 3 Yes SECTION III: SPECIALTY AND PRACTICE INFORMATIONSPECIALTY INFORMATIONPrimary Specialty: Medical Specialty Primary Specialty: % of Practice (Primary and Sub must total 100%) Primary Specialty: Board Certified? Yes No Primary Specialty: Board Eligible? Yes No Sub Specialty: Medical Specialty Sub Specialty: % of Practice (Primary and Sub must total 100%)Sub Specialty: Board Certified? Yes No Sub Specialty: Board Eligible? Yes No Medical ProceduresPlease check the appropriate box, indicating the extent of surgery you perform:(Required) No Surgery except incisions of boils, cysts, circumcisions (newborns), or other superficial abscesses or suturing minor lacerations. Minor Surgery includes most procedures performed under local anesthesia; or assisting in major surgery on your own patients. Major Surgery includes major surgical procedures done under general, spinal or caudal anesthesia; or assisting in major surgery on other than your own patients. If you assist in surgery, please provide the number of procedures performed annually: If you are Assisting in major surgery on patients other than your own (# per year): Please check the procedures, which you perform, for which you are requesting coverage. Please check any procedure that you have performed in the last 5 years.(Required) Abdominoplasty Abortion Acupuncture or Acupressure Addiction Medicine Anesthesia (General/Spinal/Caudal) Angiography/Arteriography Angioplasty Appendectomy Arthroscopy Bariatric Surgery Botox Bronchoscopy Cardiac Catheterization Chelation Therapy Cryosurgery (internal lesions) D&C Dermatology Procedures Endoscopic Procedures Fertility/Infertility Treatment Fracture Reductions General Surgery Hysterectomy Lithotripsy Laparoscopy Needle Biopsy Pain Management Radiofrequency Procedures Prenatal Care Obstetrics Orthopedics Permanent Pacemakers Plastics Prolotherapy Radiology Radiation/X-Ray Therapy Renal Dialysis Sclerotherapy Spinal Surgery Thoracic Surgery Tonsillectomy/Adenoidectomy Transgender Surgery Trauma Surgery Tubal Ligations Vascular Surgery Vasectomies Wound Care Other Medical/Procedural Techniques not listed above (please describe): abortion 1st Trimester 2nd Trimester 3rd Trimester abortion: Elective Elective Therapeutic abortion: Elective_% of practice abortion: Therapeutic_% of practice Addiction Medicine:Suboxone Therapy Yes No Bariatric Surgery Gastric Bands Bypass or Staples Gastric Sleeve Other Dermatology Procedures Chemabrasion/Dermabrasion Deep Chemical Peels Superficial Chemical Peels Hair Transplants Liposuction/Lipoinjection Silcone Injections Skin Flaps/Grafts Endoscopic Procedures Sigmoidoscopy only Other than Sigmoidoscopy Laser Therapy Fracture Reductions Open Closed Needle Biopsy Type Pain Management Implants (incl. Intrathecal Pumps) Medication only Nerve Block (Spinal, Paraspinal, Paravertebral, Epidural) Nerve Block (Other) Prenatal Care Including 1st Trimester only Including 1st and 2nd Trimesters Prenatal to term, no delivery Prenatal to term, incl. delivery Obstetrics: Performing_Assist only 1 Performing Assist Only Obstetrics C-Sections Vaginal Births VBACs Orthopedics Including Spine No Spine Plastics Reconstructive Cosmetic Radiology Interventional Radiopaque Dye Wound Care Hyperbaric Medicine Surgical Debridement Other Medical/Procedural Techniques not listed above: Please describe Do you perform or provide any of the following services as a part of your practice?If so, please describe.Experimental Surgery Yes No Experimental Surgery_% of practice Experimental Surgery_Description Independent Medical Exams Yes No Independent Medical Exams_% of practice Independent Medical Exams_Description Weight Control Medication Yes No Weight Control Medication_Description Weight Control Medication_% of practice Telemedicine Yes, If you are practicing telemedicine, please complete and return the Telemedicine Supplemental Questionnaire. No Telemedicine_% of practice Telemedicine_Description Practice InformationDo you currently practice at any additional locations other than the primary office location listed in Section I: General Information?(Required) Yes No Practice Name Practice Location Practice Hours Practice Start Date Practice Complete Date Practice Name_2 Practice Location_2 Practice Hours_2 Practice Start Date_2 Practice Complete Date_2 Practice Name_3 Practice Location_3 Practice Hours_3 Practice Start Date_3 Practice Complete Date_3 Medical Specialties Change?Have you changed medical specialties, hours, or location within the last 5 years?(Required) Yes No Medical Location(Required) Medical Hours(Required) Medical Specialty(Required) Medical Period_From(Required) Medical Period_To(Required) Medical Tail Purchased(Required) Yes No Medical Location_2 Medical Hours_2 Medical Specialty_2 Medical Period_From_2 Medical Period_To_2 Medical Tail Purchased_2 Yes No Medical Location_3 Medical Hours_3 Medical Specialty_3 Medical Period_From_3 Medical Period_To_3 Medical Tail Purchased_3 Yes No Hospital PrivilegesDo you currently have Hospital Privileges?(Required) Yes No Hospital Name Hospital Location Type of Privileges Staff Courtesy Other Type of Privileges: Other Hospital Name_2 Hospital Location_2 Type of Privileges_2 Staff Courtesy Other Type of Privileges: Other_2 Hospital Name_3 Hospital Location_3 Type of Privileges_3 Staff Courtesy Other Type of Privileges: Other_3 Comments Do you work as an emergency room physician, other than for maintaining hospital privileges? Yes No Do you work as an emergency room physician, If yes separate coverage? Yes No Do you work as an emergency room physician, If yes hrs per month? Are you a proprietor, owner, director, partner, superintendent, executive officer, administrative officer, medical director, or attending physician at any of the following: Hospital Birthing Clinic Prepaid Health Plan Sanitarium Clinic HMO Nursing Home Laboratory Surgery Center Blood Bank Other: Are you a proprietor…attending physician at any of the following? Other_Specify Do you have separate coverage for this exposure? Yes No Do you practice medicine at the above institutions? Yes No SECTION IV: EDUCATION AND TRAININGPlease describe your medical professional education and trainingCheck this box if you have attached a current Curriculum Vitae (CV) and continue with Section V, Entity/Organization Information.(Required) Yes Medical School: School/Facility Medical School: Location Medical School: Specialty Medical School: Start date Medical School: Complete date Internship: School/Facility Internship: Location Internship: Specialty Internship: Start date Internship: Complete date Residency: School/Facility Residency: Location Residency: Specialty Residency: Start date Residency: Complete date Fellowship: School/Facility Fellowship: Location Fellowship: Specialty Fellowship: Start date Fellowship: Complete date Other Training: Specialty Other Training: Location Other Training: School/Facility Other Training: Start date Other Training: Complete date Please explain any gaps in training Are you a Foreign Medical School Graduate? Yes, please provide a copy of your USMLE No Are you certified in: ACLS ATLS PALS Other Are you certified in: Other_Specify Are you entering private practice for the first time following your residency, training, military services, or an academic position? Yes No SECTION V: ENTITY/ORGANIZATION INFORMATIONIndicate which practice organization applies to you: Solo Unincorporated Solo Corporation Partner or Partnership Independent Contractor Corporate Shareholder Employee Government Employee Other: Indicate which practice organization applies to you: Other_Specify Name of Entity/Organization: Do you wish for coverage for this Entity/Organization? Yes, a separate Entity/Organization application is required. Note: Separate limits are not available in all states. No Limit Type Shared Separate Is there any other name under which you practice(i.e. DBA, unincorporated name, trade name)? Yes No Is there any other name under which you practice? Name Is there any other name under which you practice? Description Is there any other name under which you practice? Name_2 Is there any other name under which you practice? Description_2 Is there any other name under which you practice? Name_3 Is there any other name under which you practice? Description_3 MEDICAL STAFFDo you currently employ, independently contract, or otherwise maintain an association with any other health care providers? Yes No Check this box if you have included a current roster in place of completing the table below Yes # Employed Physicians and Surgeons # Contracted Physicians and Surgeons # Supervise only Physicians and Surgeons Medical Staff: Coverage Desired_1 Yes No # Employed Dentists # Contracted Dentists # Supervise only Dentists Medical Staff: Coverage Desired_2 Yes No # Employed Podiatrist # Contracted Podiatrist # Supervise only Podiatrist Medical Staff: Coverage Desired_3 Yes No # Employed Fellows # Contracted Fellows # Supervise only Fellows Medical Staff: Coverage Desired_4 Yes No # Employed Residents # Contracted Residents # Supervise only Residents Medical Staff: Coverage Desired_5 Yes No # Employed Interns # Contracted Interns # Supervise only Interns Medical Staff: Coverage Desired_6 Yes No # Employed CRNAs # Contracted CRNAs # Supervise only CRNAs Medical Staff: Coverage Desired_7 Yes No # Employed Midwife # Contracted Midwife # Supervise only Midwife Medical Staff: Coverage Desired_8 Yes No # Employed Nurse Practitioner #Contracted Nurse Practitioner # Supervise only Nurse Practitioner Medical Staff: Coverage Desired_9 Yes No # Employed Optometrist # Contracted Optometrist # Supervise only Optometrist Medical Staff: Coverage Desired_10 Yes No # Employed Perfusionist # Contracted Perfusionist # Supervise only Perfusionist Medical Staff: Coverage Desired_11 Yes No # Employed Physician Assistants # Contracted Physician Assistants # Supervise only Physician Assistants Medical Staff: Coverage Desired_12 Yes No # Employed Radiology Assistants # Contracted Radiology Assistants # Supervise only Radiology Assistants Medical Staff: Coverage Desired_13 Yes No # Employed Surgical Assistants # Contracted Surgical Assistants # supervise only Surgical Assistants Medical Staff: Coverage Desired_14 Yes No 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.Health care providers you associate with: name Health care providers you associate with: Specialty Health care providers you associate with: Insurer Health care providers you associate with: License Health care providers you employ: Association Employed Supervise Contracted Other Health care providers you employ: Association_Other_Specify Health care providers you associate with: State Date health care providers you associate with: name_2 health care providers you associate with: Specialty_2 health care providers you associate with: Insurer_2 health care providers you associate with: License_2 health care providers you employ: Association_2 Employed Supervise Contracted Other health care providers you employ: Association_Other_Specify_2 health care providers you associate with: State Date_2 health care providers you associate with: name_3 health care providers you associate with: Specialty_3 health care providers you associate with: Insurer_3 health care providers you associate with: License_3 health care providers you employ: Association_3 Employed Supervise Contracted Other health care providers you employ: Association_Other_Specify_3 health care providers you associate with: State Date_3 SECTION VI: CLAIMS INFORMATIONWithin the past 10 years, has any claim or suit for alleged malpractice ever been brought against you, or are you aware of circumstances that might reasonably lead to such a claim or suit?(Required) Yes No 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.Total Number of Claims and Suites Total Number of Claims and Suites: # Open/Reserved: Total Number of Claims and Suites: # Closed Total Number of Incidents Total Number of Incidents: # Open/Reserved: Total Number of Incidents: # Closed Have you made any changes to your practice as a result of any claims? Yes No Have you made changes to your practice as a result of claims suits and incidents SECTION VII: ADDITIONAL INFORMATIONFor each question below that you answer “Yes,” please provide a complete explanation in the Remarks Section.Has your medical professional liability insurance ever been declined, non-renewed or cancelled including cancellation for nonpayment of premium? (Not applicable to Missouri applicants) Yes No Has your medical professional liability insurance ever been surcharged, reduced, or issued with a deductible or other special terms? Yes No Have you been charged or convicted of any crime other than minor traffic violations? Yes No Have you ever had your medical license or DEA license revoked, limited, refused, suspended, or denied? Yes No Have you ever failed to pass a Board Examination? Yes No Have your hospital privileges ever been surrendered, limited, or revoked, whether voluntarily or involuntarily? Yes No Have your hospital privileges been expanded or reduced in the last 12 months? Yes No Has membership of any Professional Association or Society ever been refused, revoked, or limited in any way? Yes No Have you ever had a complaint filed, been censured, or had a private reprimand with a County or State Medical Society? Yes No During the past year, have you incurred or become aware of having an illness or physical disability that impairs, or could impair, your ability to practice your medical specialty? Yes, a statement from your physician attesting to your fitness to practice your specialty must accompany this application. No Have you ever been treated for alcoholism, narcotic addiction, or mental impairment? Yes, please provide the details of the rehabilitation program including dates of treatment. No Have you ever been accused of sexual misconduct? Yes No Have you ever had any contact of a sexual nature with a patient or former patient? Yes No Do you know of any individual who works on your behalf that has a prior history or propensity for sexual misconduct? Yes No Have you treated or will you treat celebrities or professional athletes? Yes No Have you practiced or will you practice at a prison, correctional facility, or other similar facility, or have you provided or will you provide health care services to prisoners or inmates? Yes No Do you enter into arbitration or similar agreements with your patients? Yes, please attached a copy of the agreement(s). No Do you participate in clinical trails? Yes, please complete our clinical trials questionnaire. No Do you use any non-FDA approved devises, drugs, or procedures? Yes No SECTION VIII: MISCELLANEOUSNOTICE FOR NEW JERSEY APPLICANTSConsent to Settle Provision Maintain the Settlement of a Claim provision requiring my consent to settle a claim on my behalf. Remove the Settlement of a Claim provision and apply the 1% discount to my premium. Consent to Settle Provision The policy for which you are applying states that the Company will not settle a claim without the insured’s consent to do so. At your option, that provision can be deleted and replaced, permitting the Company to settle a claim without your consent. If you choose this option, you will receive a 1% premium discount. Please select an option:REMARKS SECTIONPlease provide any additional information/explanations for your application below.AGREEMENTS AND NOTICESI 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 The Company. 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.Agreements and Notices: Applicant Signature(Required) Reset signature Signature locked. Reset to sign again Agreements and Notices: Date mmyydddd(Required) Agreements and Notices: Printed Name(Required) Agreements and Notices: Title(Required) CLAIM | SUIT | INCIDENT SUPPLEMENTAL FORMAttach 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.Patient Name Age Claims_MaleFemale Male Female Date of Incident mmddyyyy Location of Incident Name of Insurer Date Reported to Insurer mmddyyyy Claim Type Suit Demand for Money Incident Only Notice of Intent to Sue Request for Records Other: Claims Form_Type: Other Summary of condition/diagnosis at time of incidentDescription of treatment rendered, including dates:Allegations:Other persons and entities involvedStatus/Disposition Open Closed without indemnity payment Settled Judgment/Verdict for defense Judgment/Verdict for plaintiff Describe current status and defense strategy Status/Disposition Date: mmddyyyy Status/disposition:Amount reserved for you: Indemnity Status/disposition:Amount reserved for you: Defense Status/disposition:Amount reserved for other defendants: Indemnity Status/disposition:Amount reserved for other defendants: Defense Status/disposition:Amount paid on your behalf: Indemnity Status/disposition:Amount paid on your behalf: Defense Status/disposition:Amount paid on behalf of other defendants: Indemnity Status/disposition:Amount paid on behalf of other defendants: Defense Has there been a change in practice as a result of this claims, suite, or incident? Yes No Please Explain: I understand this information is part of my Application ClaimsForm_Printed Name Signature Date: mmddyyyy Consent Claim Form(Required) I AgreeSignature1 Reset signature Signature locked. Reset to sign again SavePrintPrint
