KETTERING PHYSICIAN NETWORK
Allied Provider Professional Liability Insurance Application
I. GENERAL INFORMATION
REQUESTED EFFECTIVE DATE: Click here to enter text.
A. LAST NAME: Click here to enter text.
FIRST NAME: Click here to enter text.
MIDDLE NAME: Click here to enter text. SUFFIX: Click here to enter text.
MALE ☐ FEMALE ☐
DATE OF BIRTH: Click here to enter text.
SOCIAL SECURITY NUMBER (REQUIRED): Click here to enter text.
NATIONAL PROVIDER IDENTIFIER NUMBER: Click here to enter text.
MOBILE NUMBER: Click here to enter text.
BUSINESS PHONE: Click here to enter text. BUSINESS FAX: Click here to enter text.
EMAIL ADDRESS: Click here to enter text.
PRACTICE MANAGER NAME:
B. IF YOU HAVE A WEB ADDRESS, PLEASE PROVIDE THE WEBSITE ADDRESS (URL):
Click here to enter text.
C. RESIDENCE ADDRESS:
STREET NUMBER: Click here to enter text.
APARTMENT NUMBER: Click here to enter text.
CITY: Click here to enter text. STATE: Click here to enter text. ZIP CODE: Click here to enter text.
COUNTY: Click here to enter text.
I. GENERAL INFORMATION (CONTINUED)
D. PRACTICE LOCATION(S): (PLEASE LIST PRIMARY LOCATION FIRST. COMBINED PERCENTAGE OF PRACTICE FOR ALL LOCATIONS MUST TOTAL 100%.)
1. PERCENT OF PRACTICE: Click here to enter text.
PRACTICE/HOSPITAL NAME: Click here to enter text.
STREET ADDRESS (INCLUDE SUITE): Click here to enter text.
STATE: Click here to enter text. COUNTY: Click here to enter text.
START DATE AT LOCATION: Click here to enter text.
2. PERCENT OF PRACTICE: Click here to enter text.
PRACTICE/HOSPITAL NAME: Click here to enter text.
STREET ADDRESS (INCLUDE SUITE): Click here to enter text.
STATE: Click here to enter text. COUNTY: Click here to enter text.
START DATE AT LOCATION: Click here to enter text.
3. PERCENT OF PRACTICE: Click here to enter text.
PRACTICE/HOSPITAL NAME: Click here to enter text.
STREET ADDRESS (INCLUDE SUITE): Click here to enter text.
STATE: Click here to enter text. COUNTY: Click here to enter text.
START DATE AT LOCATION: Click here to enter text.
II. PROFESSIONAL INFORMATION
A. WHAT IS YOUR PRESENT SPECIALTY? Click here to enter text.
WHAT IS YOUR SUB-SPECIALTY? Click here to enter text.
II. PROFESSIONAL INFORMATION (CONTINUED)
B. EDUCATION / TRAINING
NAME OF SCHOOL: Click here to enter text.
CITY: Click here to enter text. STATE: Click here to enter text.
COUNTRY: Click here to enter text.
CREDENTIALS (CRNA, OD, RN etc.): Click here to enter text.
ATTENDANCE DATES-START TO COMPLETION (MM/YYYY):
FROM: Click here to enter a date. TO: Click here to enter a date.
C. TO WHICH HEALTHCARE PROFESSIONAL SOCIETIES OR ASSOCATIONS DO YOU BELONG?
Click here to enter text.
D. ARE YOU REQUIRED TO BE LICENSED IN THE STATE(S) WHERE YOU PRACTICE?
YES ☐ NO ☐
IF YES, STATES IN WHICH YOU HOLD A LICENSE TO PRACTICE:
1. STATE: Click here to enter text. LICENSE #: Click here to enter text.
ACTIVE ☐ INACTIVE ☐ TEMPORARY ☐ PENDING ☐
2. STATE: Click here to enter text. LICENSE #: Click here to enter text.
ACTIVE ☐ INACTIVE ☐ TEMPORARY ☐ PENDING ☐
3. STATE: Click here to enter text. LICENSE #: Click here to enter text.
ACTIVE ☐ INACTIVE ☐ TEMPORARY ☐ PENDING ☐
E. HAVE YOU COMPLETED A RISK MANAGEMENT COURSE WITHIN THE LAST 12 MONTHS? YES ☐ NO ☐
F. DO YOU INDEPENDENTLY PRESCRIBE/ ORDER DRUGS WITHOUT PHYSICIAN REVIEW?
YES ☐ NO ☐
G. INDICATE THE AVERAGE HOURS PER WEEK FOR WHICH YOU REQUIRE PROFESSIONAL LIABILITY INSURANCE COVERAGE:
Click here to enter text. HOURS
H. INDICATE THE AVERAGE HOURS PER WEEK DEVOTED TO TREATING OR REVIEWING TREATMENT OF FEDERAL PRISON INMATES. Click here to enter text.HRS ☐NONE
1. IF APPLICABLE, PLEASE IDENTIFY THE NAME OF THE FEDERAL PENITENTIARY OR FACILITY. Click here to enter text.
II. PROFESSIONAL INFORMATION (CONTINUED)
I. INDICATE THE AVERAGE HOURS PER WEEK DEVOTED TO TREATING NON-FEDERAL PRISON INMATES. Click here to enter text.HRS ☐NONE
J. WILL YOU BE PERFORMING ACTIVITIES WHICH WILL BE COVERED BY ANOTHER PROFESSIONAL LIABILITY POLICY? YES ☐ NO ☐
IF YES, ARE YOU A(N):
EMPLOYEE ☐ INDEPENDENT CONTRACTOR ☐
RESIDENT/FELLOW ☐ FACULTY ☐
PRACTICE NAME: Click here to enter text.
LOCATION: Click here to enter text.
NAME OF INSURER: Click here to enter text.
K. HAVE YOU EVER BEEN INDICTED FOR, CHARGED WITH, OR CONVICTED OF ANY ACT COMMITTED IN VIOLATION OF ANY LAW OR ORDINANCE, OTHER THAN TRAFFIC OFFENSES, OR HAD YOUR HOSPITAL PRIVILEGES, DEA LICENSE, MEDICAL LICENSE OR REIMBURSEMENT PRIVILEGES REFUSED, DENIED, REVOKED, SUSPENDED, RESTRICTED, SUBJECT TO A REPRIMAND, PLACED ON PROBATION OR VOLUNTARILY SURRENDERED? YES ☐ NO ☐
IF YES, PLEASE INDICATE THE DATE(S) AND EXPLAIN:
DATE (MM/YYYY): Click here to enter text.
DETAILS: Click here to enter text.
L. HAS ANY PROFESSIONAL LIABILITY INSURANCE COMPANY EVER DECLINED, REFUSED, CANCELED, OR NON-RENEWED YOUR COVERAGE? YES ☐ NO ☐
IF YES, PLEASE INDICATE THE DATE(S) AND EXPLAIN:
DATE (MM/YYYY): Click here to enter text.
DETAILS: Click here to enter text.
M. HAVE YOU EVER BEEN ACCUSED OF SEXUAL MISCONDUCT OF ANY KIND?
YES ☐ NO ☐
IF YES, PLEASE INDICATE THE DATE(S) AND EXPLAIN:
DATE (MM/YYYY): Click here to enter text.
DETAILS: Click here to enter text.
II. PROFESSIONAL INFORMATION (CONTINUED)
N. HAVE YOU INCURRED OR BECOME AWARE OF HAVING A CONDITION THAT IMPAIRS YOUR ABILITY TO PRACTICE YOUR MEDICAL SPECIALTY?
(i.e. CONVULSIVE DISORDERS, MENTAL ILLNESS, MULTIPLE SCLEROSIS, ADDICTION OF ALCOHOL, NARCOTICS OR OTHER CONTROLLED SUBSTANCES, etc.) YES ☐ NO ☐
IF YES, STATE CONDITION(S) AND DATES AND IDENTIFY YOUR TREATING PHYSICIAN(S) IN THE SPACE PROVIDED BELOW. IN THE EVENT OF ANY SUCH IMPAIRMENT, A STATEMENT FROM YOUR PHYSICIAN ATTESTING TO YOUR FITNESS TO PRACTICE YOUR SPECIALTY MUST ACCOMPANY THIS APPLICATION.
TYPE(S) OF ILLNESS: Click here to enter text.
DATE(S) OF TREATMENT(S):
FROM (MM/YYYY): Click here to enter text. TO (MM/YYYY): Click here to enter text.
NAME OF TREATING PHYSICIAN(S): Click here to enter text.
ADDRESS(ES): Click here to enter text.
III. LOSS INFORMATION
PLEASE COMPLETE A LOSS INFORMATION SUPPLEMENT FORM FOR EACH WRITTEN REQUEST, INCIDENT, CLAIM OR SUIT (A, B, OR C) BELOW.
(LAST 2 PAGES OF APPLICATION.)
REPORT PROFESSIONAL LIABILITY AND MALPRACTICE RELATED MATTERS INCLUDING, BUT NOT LIMITED TO, BOARD COMPLAINTS, ETC.
FOR QUESTIONS B AND C BELOW, REPORT ALL MATTERS THAT MIGHT REASONABLY LEAD TOA CLAIM OR SUIT BEING BROUGHT AGAINST YOU, EVEN IF YOU BELIEVE THE CLAIM OR SUIT WOULD BE WITHOUT MERIT.
A. ARE YOU NOW, OR HAVE YOU EVER BEEN INVOLVED, IN A CLAIM OR SUIT ARISING OUT OF THE RENDERING OR FAILURE TO RENDER PROFESSIONAL SERVICES? YES ☐ NO ☐
IF YES, HOW MANY? Click here to enter text.
III. LOSS INFORMATION (CONTINUED)
B. ARE YOU AWARE OF ANY COMPLICATION, INCIDENT OR ADVERSE OUTCOME RESULTING IN INJURY OR DEATH THAT MIGHT REASONABLY RESULT IN A CLAIM OR SUIT AGAINST YOU?
(THIS INCLUDES, BUT IS NOT LIMITED TO, THE FOLLOWING:
- AMPUTATION - LOSS OF MAJOR ORGAN FUNCTION
- DEATH - LOSS OF VISION
- PERMANENT NEUROLOGICAL INJURY
YES ☐ NO ☐ IF YES, HOW MANY? Click here to enter text.
C. IN THE LAST 12 MONTHS, HAVE YOU OR ANYONE FROM YOUR PRACTICE RECEIVED A WRITTEN REQUEST FROM AN ATTORNEY FOR TREATMENT RECORDS CONCERNING ANY OF YOUR CURRENT OR FORMER PATIENTS THAT MIGHT REASONABLY RESULT IN A CLAIM OR SUIT AGAINST YOU?
YES ☐ NO ☐ IF YES, HOW MANY? Click here to enter text.
IV. COVERAGE INFORMATION
A. KETTERING PHYSICIAN NETWORK PARTICIPATES IN THE SELF-INSURED INSURANCE PROGRAM UNDERWRITTEN AND MANAGED BY THE KETTERING HEALTH NETWORK RISK MANAGEMENT DEPARTMENT. DETAILS REGARDING COVERAGE FOR ALLIED PROVIDERS UNDER THIS PROGRAM ARE AS FOLLOWS:
COVERAGE TYPE: OCCURRENCE
COVERAGE LIMITS: $4,000,000
B. PLEASE LIST ALL PREVIOUS PROFESSIONAL LIABILITY INSURERS WITHIN THE PAST 10 YEARS:
1. CURRENT INSURER: Click here to enter text.
COVERAGE TYPE: OCCURRENCE ☐ CLAIMS–MADE ☐
EFFECTIVE DATES (MM/DD/YYYY):
BEGIN DATE: END DATE:
2. PREVIOUS INSURER: Click here to enter text.
COVERAGE TYPE: OCCURRENCE ☐ CLAIMS–MADE ☐
EFFECTIVE DATES (MM/DD/YYYY):
BEGIN DATE: END DATE:
3. PREVIOUS INSURER: Click here to enter text.
COVERAGE TYPE: OCCURRENCE ☐ CLAIMS–MADE ☐
EFFECTIVE DATES (MM/DD/YYYY):
BEGIN DATE: END DATE:
IV. COVERAGE INFORMATION (CONTINUED)
C. IF THE MOST RECENT PRIOR COVERAGE WAS ISSUED ON A CLAIMS-MADE BASIS, PLEASE COMPLETE ONE OF THE FOLLOWING:
☐ AN EXTENDED REPORTING ENDORSEMENT (TAIL COVERAGE) HAS BEEN OR WILL BE PURCHASED.
☐ AN EXTENDED REPORTING ENDORSEMENT (TAIL COVERAGE) HAS NOT AND WILL NOT BE PURCHASED (PLEASE INITIAL BELOW)
I WILL NOT PURCHASE TAIL COVERAGE (REPORTING ENDORSEMENT) FROM MY CURRENT CARRIER WHERE I AM INSURED UNDER A CLAIMS-MADE POLICY. I REALIZE THAT MY FAILURE TO PURCHASE SUCH COVERAGE FROM MY CURRENT INSURER WILL RESULT IN AN UNINSURED EXPOSURE FOR ANY CLAIMS WHICH MAY ARISE AS A RESULT OF PROFESSIONAL SERVICES RENDERED WHILE INSURED BY MY CURRENT INSURER’S POLICY. I UNDERSTAND THAT THE POLICY FOR WHICH I AM APPLYING WITH KETTERING PHYSICIAN NETWORK, IF OFFERED, WILL NOT PROVIDE PRIOR ACTS COVERAGE.
INITIAL HERE: Click here to enter text.
VII. CONSENT TO SETTLE CLAIMS & ASSIGNMENT OF RIGHTS TO CANCEL COVERAGE
A. KETTERING PHYSICIAN NETWORK HAS THE RIGHT TO SETTLE ANY CLAIMS BROUGHT AGAINST ME OR MY CORPORATION W WITHOUT MY CONSENT. BY INITIALING, I ACKNOWLEDGE THE AFOREMENTIONED AND ASSIGN THE CONSENT TO SETTLE ALL FUTURE CLAIMS BROUGHT AGAINST ME OR MY CORPORATION TO THE FOLLOWING EMPLOYER:
KETTERING PHYSICIAN NETWORK
10050 INNOVATION DRIVE
MIAMISBURG, OH 45342
INITIAL HERE: Click here to enter text.
B. KETTERING PHYSICIAN NETWORK HAS THE RIGHT TO CANCEL MY POLICY AND/OR MY CORPORATION’S POLICY, AND RECEIVE ANY UNEARNED PREMIUM. BY INITIALING, I ACKNOWLEDGE THE AFOREMENTIONED AND ASSIGN TO THE FOLLOWING EMPLOYER BOTH THE RIGHT TO CANCEL MY POLICY AND RECEIVE ANY UNEARNED PREMIUM.
KETTERING PHYSICIAN NETWORK
10050 INNOVATION DRIVE
MIAMISBURG, OH 45342
INITIAL HERE: Click here to enter text.
IX. NOTICES AND AGREEMENTS
ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT, IS GUILTY OF INSURANCE FRAUD.
I HEREBY DECLARE THAT THE ABOVE STATEMENTS AND PARTICULARS, OR ANY STATEMENTS AND PARTICULARS MADE IN ANY AND ALL DOCUMENTS, APPLICATIONS, SUPPLEMENTAL PAGES OR OTHER ATTACHMENTS (HEREINAFTER "ATTACHMENTS") FOR THE PURPOSES OF THE INITIAL OR RENEWAL APPLICATION ARE TRUE, THAT I HAVE NOT KNOWINGLY SUPPRESSED OR MISSTATED ANY MATERIAL FACTS, AND THAT I AGREE THAT THIS APPLICATION, AND ANY ATTACHMENTS, SHALL BE THE BASIS OF THE CONTRACT WITH KETTERING PHYSICIAN NETWORK (THE "COMPANY").
I AGREE TO NOTIFY THE COMPANY IF THERE ARE ANY FUTURE MATERIAL CHANGES IN ANY ANSWER TO THIS APPLICATION, OR ITS ATTACHMENTS, INCLUDING WITHOUT LIMITATION, ANY CHANGE IN MY PROFESSIONAL SPECIALTY, AFFILIATION OR WORKING ARRANGEMENT WITH ANY OTHER DENTIST, PHYSICIAN, FIRM OR PROFESSIONAL ASSOCIATION.
I UNDERSTAND THAT ANY MATERIAL MISREPRESENTATION OR OMISSION MADE BY ME ON THIS APPLICATION MAY ACT TO RENDER ANY CONTRACT OF INSURANCE NULL AND VOID AND WITHOUT EFFECT OR PROVIDE THE COMPANY THE RIGHT TO RESCIND IT. BY MAKING THIS APPLICATION, I AM NOT RELYING UPON ANY ORAL OR WRITTEN REPRESENTATION THAT COVERAGE HAS OR WILL BE EXTENDED OR THAT A POLICY OF INSURANCE WILL BE ISSUED.
I FURTHER UNDERSTAND AND AGREE THAT I HAVE NO RIGHT TO DEMAND OR EXPECT COVERAGE UNTIL THE COMPANY HAS: (1) RECEIVED MY COMPLETED APPLICATION AND
(2) PROVIDED APPROVAL AND CERTIFICATE OF INSURANCE.
I AGREE THAT IF I FAIL TO COMPLY WITH THESE TERMS I WILL HAVE NO COVERAGE FOR ANY CLAIM UNDER ANY POLICY OF INSURANCE FOR WHICH I AM APPLYING.
I ALSO UNDERSTAND THAT THE COMPANY MAY WISH TO CONTACT PERSONS, HOSPITALS, SCHOOLS, EMPLOYERS, INSURANCE AGENTS, PROFESSIONAL LIABILITY INSURERS OR OTHER ENTITIES TO VERIFY AND/OR ASCERTAIN INFORMATION REGARDING MY CREDENTIALS AND BACKGROUND BOTH PRIOR TO, AND IF ISSUED, AFTER THE ISSUANCE OF A CONTRACT OF INSURANCE. THEREFORE, I HEREBY CONSENT AND INSTRUCT ANY SUCH PERSON, HOSPITAL, SCHOOL, EMPLOYER, INSURANCE AGENT, PROFESSIONAL LIABILITY INSURER OR OTHER ENTITY TO RELEASE TO THE COMPANY ANY INFORMATION REGARDING ME, WHICH THE COMPANY, IN GOOD FAITH, BELIEVES TO BE APPLICABLE AND PERTINENT TO THIS APPLICATION AND IF ISSUED, THE CONTRACT OF INSURANCE ISSUED HEREUNDER.
APPLICANT SIGNATURE: ______
(Ink signature required)
DATE SIGNED: ______
PRINTED NAME: ______
LOSS INFORMATION SUPPLEMENT FORM
NOTE: ADDITIONAL DOCUMENTATION MAY BE REQUESTED AT KETTERING PHYSICIAN NETWORK’S DISCRETION.
APPLICANT’S NAME: Click here to enter text.
A. PATIENT/CLAIMANT INFORMATION
LAST NAME: Click here to enter text.
FIRST NAME: Click here to enter text.
AGE: Click here to enter text.
B. DATE OF TREATMENT AND/OR SURGERY WHICH LED, OR COULD LEAD, TO ALLEGATIONS AGAINST YOU: MM YYYY: Click here to enter text.
C. DATE OF NOTICE RECEIVED, IF APPLICABLE.
MM YYYY: Click here to enter text.
D. HAS THIS MATTER BEEN REPORTED TO YOUR CURRENT OR FORMER INSURER?
YES ☐ NO ☐
IF YES, DATE REPORTED TO YOUR CURRENT OR FORMER INSURER:
MM YYYY: Click here to enter text.
CURRENT OR FORMER INSURER NAME: Click here to enter text.
IF NO, PLEASE EXPLAIN: Click here to enter text.
D.
E. NATURE OF ALLEGATIONS OR POTENTIAL ALLEGATIONS:
CONDITION TREATED: Click here to enter text.
TREATMENT PROVIDED: Click here to enter text.
ALLEGED NEGLIGENCE: Click here to enter text.
ALLEGED INJURY: Click here to enter text.
F. NAME OF ALL OTHER DOCTOR(S), HOSPITAL(S), OR HEALTH CARE PROVIDER(S), IF ANY, INVOLVED:
Click here to enter text.
LOSS INFORMATION SUPPLEMENT FORM (CONTINUED)
G. CURRENT STATUS: OPEN ☐ CLOSED ☐
IF CLOSED:
1. DATE OF CLOSING: Click here to enter text.
2. WAS A PAYMENT MADE? YES ☐ NO ☐
IF YES, DID YOU CONSENT TO THE SETTLEMENT? YES ☐ NO ☐
TOTAL AMOUNT OF SETTLEMENT OR AWARD: Click here to enter text.
TOTAL AMOUNT OF SETTLEMENT OR AWARD PAID ON YOUR BEHALF:
Click here to enter text.
IF OPEN:
1. INDICATE RESERVE DOLLAR VALUE ESTABLISHED BY INSURER: Click here to enter text.
H. PLEASE PROVIDE A NARRATIVE DESCRIPTION OF ALL RELEVANT FACTS, INCLUDING, BUT NOT LIMITED TO, YOUR INVOLVEMENT IN THE TREATMENT AND/OR SURGERY:
Click here to enter text.
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