Health Care Facilities Application For Professional Liability Insurance
PLEASE TYPE OR PRINT CLEARLY ALL RESPONSES AND ANSWER ALL QUESTIONS.
COVERAGE WILL NOT BE CONSIDERED UNTIL THIS APPLICATION IS COMPLETE.
I. AGENT (Do not complete this section if you are insured directly with MMIC.)
Agent Name/ Agency Name
/ Address
City
/ State
/ Zip
/ Telephone Number
/ Fax Number
II. NAME AND ADDRESS
A. Client Information
Facility Name / Tax ID Number:Applicant’s legal structure (Check all that apply):
Sole Proprietorship Corporation Partnership Joint Venture For Profit Not for Profit
Facility Address (Street, City, State, Zip Code)
/ County
Corporate Telephone Number
/ Corporate Fax Number
/ Facility E-Mail Address
Provide a brief description of your business:
Tell us who our Risk Management representatives may contact for a telephone or on-site review of your facility:
Name/Title:
Telephone Number
/ Fax Number
/ Facility E-Mail Address
B. Effective Date of Coverage
Insurance coverage effective date to commence at 12:01 a.m. on: / Month Date YearAre you currently enrolled in a Patients’ Compensation Fund?
Yes No
C. Location
Complete the following information for each location you own. Location number 1 should be the main business address
Business Name & Address(Street, City, State, Zip Code) / Your Ownership
Percentage / Description
of Operations / Is coverage desired for this location?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
D. Financial Interest
List the following details for each medical professional that has a financial interest in your facility.
Name / Profession / Policy No. / Interest(Owner, director, etc.) / Patient Care
For the Facility Outside Practice
% / %
% / %
% / %
% / %
III. PROFESSIONAL LIABILITY COVERAGE
A. Primary Professional Liability Limits
Limits of Liability Desired (Limits indicated are per claim and aggregate)$1,000,000/$3,000,000 / $3,000,000/$5,000,000 / Other-Specify
$2,000,000/$4,000,000 / $4,000,000/$6,000,000
$200,000/$600,000(NE only) / $5,000,000/$7,000,000
B. Deductibles: (Event Deductible/Total Deductible
$10,000/$50,000 / $25,000/$125,000 / $50,000/$250,000
C. I am applying for retroactive coverage / Yes No / Retroactive Date:
If Yes, you must attach a copy of your most recent declarations page from your present carrier indicating the original effective date of coverage and the current expiration date.
IV. GENERAL INFORMATION
A. Indicate the number of years this facility has been:
Operating Owned by Present Owners Managed by Present Management
B. List all licenses held by your facility C. List all accreditations (e.g., JCAHO, DHHS) and
including type and expiration dates. association memberships held by your facility.
D. Has your license been suspended, revoked or placed under probation within the last 3 years? Yes No
If yes, indicate the date your license was reinstated and provide detail:
V. DESCRIPTION OF SERVICES
A. Health Cares Services Provided: (Check each box that applies, giving the requested information for each classification.
Give projected information for the next 12 months.)
ATTACH ANY BROCHURES, COURSE CATALOGS OR OTHER ADVERTISING MATERIAL USED BY YOUR FACILITY.
Counseling/Rehabilitation
/Visits*
/ Laboratory /Annual Receipts**
Cardiac Rehab / MedicalDevelopmental Disability / Ocular
Mental Health/Counseling / Optical Establishment
Physical or Occupation Rehab / Pathology
Substance Abuse Counseling / Pharmaceutical
Trauma Rehabilitation Therapy / Pharmacy
X-Ray/Imaging Center
Surgical
/ Pharmacy within Home Health AgencyEmergicenter
Surgicenter
For the following services, describe your operations in the “Other” section below.
Home Care/Hospice
/ Schools for Health Care ProfessionalsHospice Care / Chiropractic / Nursing
Intravenous Therapy / Dental / Optometry
Personal/Companion Care / Medical / Other
Rehabilitation Therapy /
Respiration Therapy /
Ambulance Companies
Skilled Care / Air AmbulanceAmbulance Service Company
Treatment
College or University Health CenterCommunity Health Center
Dialysis
Urgicenter
Other
*Visits Use a threshold count. Count each patient each time they enter your facility for health related services, regardless of the number of departments visited or the number of procedures/treatments performed within each department. For home care, count each patient each time you visit for health related services.
**Annual Receipts This figure can be found on your financial statement. Do not adjust this figure for items such as profit, uncollectible accounts or amounts billed but not paid by third party payers. However, the number must represent an annual figure.
VI. ADMINISTRATION AND STAFF
TO BE COMPLETED BY ALL APPLICANTS
A. Medical Director
Do you employ/contract a medical director? Yes No
If yes, does your Medical Director have direct patient contact? Yes No
Name of Medical Director / Specialty / Insurance Carrier and Policy Number / Check one: / Hours/Month*Employee
Contractor
B. Physicians and Surgeons
Physicians and Surgeons / Specialty / Insurance Carrier and Policy Number / Check one: / Hours/Month*Employee
Contractor
Employee
Contractor
Employee
Contractor
Employee
Contractor
*Hours/Month – indicate the total number of hours per month, on average, that each individual works for your facility.
C. Allied Health Care Professionals – indicate the number of personnel in each applicable category.
Employees / Contractors / VolunteersFull-Time / Part-Time / Full-Time / Part-Time / Full-Time / Part-Time
Dentists
Chiropractors/Podiatrist
Emergency Medical Technicians
Nurse Anesthetists
Nurse Midwives
Nurse Practitioners
Phy. Assist/Surgical First Assist.
Occupation Therapists
Oral Surgeons
Physician Therapists
RNs/LPNs/LVNs
Social Workers
Technicians
Aides
Other (describe)
D. Insurance Requirements – Please explain any no answers in the Comments Section (Part XIII).
Do you require the following health care professionals to carry professional liability insurance:
Medical Director Yes No Limits $
Physicians or Surgeons Yes No Limits $
Allied Health Care professionals Yes No Limits $
How do you verify coverage?
E. Hiring/Screening Procedures
Indicate which of the following are documented when hiring/screening professionals and clinical support staff to provide
patient care services at your facility.
Verify education background, or residency program, when applicable.
Check previous employers.
Check personal references.
Confirm hospital privileges for physicians, oral surgeons and dentist.
How often do you update your list of specific privileges?
Check for any pending license suspensions or revocations, or any pending disciplinary actions by other facilities.
Check criminal history.
Require information regarding medical professional claims history that resulted from the performance of or
failure to perform professional services.
Has any of the information collected resulted in a decision not to hire or extend privileges? Yes No
Do you have a formal documented orientation program? Yes No
If no, explain in the Comments Section (Part XIII.)
Indicate the type of employees for which you have written job descriptions. Professionals Clinical support staff None
VII. CONTRACTUAL AGREEMENTS
A. Do you lease or rent any medical equipment from other? Yes No
If yes, describe.
If yes, do you indemnify (hold harmless) the owner for liability? Yes No
B. Have you signed any contractual agreements where you have agreed to provide services to others? Yes No
If yes, describe the types of services.
C. Do you use any non-expendable medical, dental or surgical machines or devices for diagnosis monitoring for treatment
purposes? Yes No
If yes, how often is the equipment inspected and maintained?
The maintenance is performed by: Facility employees Independent contractors
If independent contractor, what limit of liability insurance do you require them to carry? $
D. If you sell or lease any medical equipment or other products in connection with your operation answer the questions below and describe the equipment or products in the Comments Section (Part XIII.)
Do you repackage or redesign the equipment you sell or lease? Yes No
Do you/your staff provide service or maintenance for the equipment you sell or lease? Yes No
If outside vendor, what limit of liability insurance do you require them to carry? $
E. Have you signed any contractual agreements where others are providing services to you or on your behalf? Yes No
If yes, describe the types of services.
Specify the minimum limits of liability insurance your require. $
How do you verify proof of this coverage?
VIII. EMERGICENTER AND SURGICENTER
Check here if not applicable to your facility and go to part IX.
A. Check if the facility is equipped with the following on a 24-hour basis:
Anesthetics C.P.R. equipment
Oxygen Electrocardiograph machine
Blood (at least “O” negative) X-Ray machine capable of accommodating an unconscious
patient in any position
B. Are the patients screened to ascertain that they are low-risk and are able to withstand having a surgical
procedure performed on an outpatient basis? Yes No
C. What is the distance and the length of travel time between your facility and the nearest hospital?
D. Do you have an agreement with a hospital allowing your patients to be directly admitted to that facility
in an emergency situations? Yes No
E. Do you have an agreement with an ambulance company for transportation of emergency cases? Yes No
F. If a critically ill patient must be transferred to a hospital, who accompanies the patient?
G. What types of follow-up procedures or counseling services are offered to patients? None
IX. REHABILITATION SERVICES
Check here if not applicable to your facility and go to part X.
A. Do you manufacture any products for sale or provide services as part of vocation training, developmental
disabilities workshops or rehabilitation? Yes No
If yes, describe and indicate annual receipts.
B. What type and frequency of counseling services do you provide?
C. What type and frequency of physical care services do you provide?
X. HOME HEALTH CARE
Check here if not applicable to your facility and go to part XI.
B. Are home health care services provided under the direction and supervision of a physician based on
physician orders and plan of care? Yes No
B. There is annual in-service training documented for each home health care staff related to:
High-technology equipment areas Sate client lifting, transferring, and ambulating techniques
Proper use of equipment Infection control and safety
Managing emergencies Other (explain)
Which of the following assessments and evaluations of employees are documented?
Training Competence level Other
XI. SCHOOLS FOR HEALLTH CARE PROFESSIONALS
Check here if not applicable to your facility and go to part XII.
A. STUDENT AND FACULTY – Indicate the number in each applicable category.
Year of Study / Course/Program / Total # of Students Enrolled / Total # Faculty / Total Hours (Clinical & Classroom) / Total Clinical Hours Only / Length of ProgramNursing – Registered Nurses / ( )
# Years
First
Second
Third
Fourth
Nursing – LPN
/ ( )# Years
First
Second
Third
Fourth
Nursing – Nurse’s Aide / ( )
# Years
First
Second
Third
Fourth
Optometry
/ ( )# Years
First
Second
Third
Fourth
EMT
/ ( )# Years
First
Second
Third
Fourth
Other
Describe:
( ) / ( )
# Years
First
Second
Third
Fourth
Other
Describe:
( ) / ( )
# Years
First
Second
Third
Fourth
Other
Describe:
( ) / ( )
# Years
First
Second
Third
Fourth
B. In the clinical setting, are your students providing: Direct hands-on patient care Observation
C. Name and address of each facility where students areplaced for clinical experience: / Is the school required to hold the facility harmless for acts of the students?
Yes No
Yes No
Yes No
Yes No
Yes No
D. Do you provide advanced training to individuals that are currently licensed professionals? Yes No
If yes, provide a description of the training program.
E. Do you require the students to carry their own professional liability insurance? Yes No
If yes, specify the minimum limits required. $
Is proof of this coverage required? Yes No
F. Do you require the faculty to carry their own professional liability insurance? Yes No
If yes, specify the minimum limits required. $
Is proof of this coverage required? Yes No
XII. CURRENT COVERAGE AND LOSS HISTORY
Complete questions A through D for new business ONLY.
A. Current profession liability coverage.
Current Carrier: / Policy Period: From: To:Current Limit of Liability:
$ Each Claim
$ Aggregate / Deductible:
$ / Current Form of Insurance:
Occurrence
Claims-Made – Retroactive Date
B. Have you had any professional claims or suits made against your facility during the last five years? Yes No
If yes, provide the following information:
1. If a current loss summary is available from the present or previous carrier, please attach a copy.
2. If a summary is not available, attach a separate page showing the following information for each claim:
a. Date of the event and date the claim was reported to the insurance company.
b. Description (cause) of the loss or claim.
c. Location of the loss.
d. Current status (open or closed).
e. Paid amount and current reserve amount.
C. Do you have knowledge of any claims that might be made against you that might give rise to a claim
or suit in the future? If yes, please attach a description of each claim. Yes No
D. Do you have knowledge of any activities that might give rise to a claim or suite in the future? If
yes, please attach a description of each activity. (Include any non-billing or non-record transfer
related requests for medical records.) Yes No
E. For renewal business, have you reported any losses to your prior carrier during the past year? If yes,
please attach a description of each loss. Yes No
XIII. COMMENTS SECTION
Question Comments
Number
MMIC Group agrees to hold in confidence, use only for its proper business purposes and, unless otherwise constrained by law, not to re-release to third parties any and all information concerning applicant which comes into its possession. Applicant acknowledges that it is within the proper business purposes of MMIC Group to discuss any such information within its committees and boards and to communicate conclusions relating thereto to applicant and administrative or executive personnel of his employer or prospective employer.
Signing this application does not bind the Company to complete the insurance. All information requested in this application is considered material and important. If the Company agrees to be bound under the terms of this application, your policy is void if you hide any important information from us, mislead us, or attempt to defraud or lie to us about any matter contained in this application.