Physician Application

 
  • GENERAL INFORMATION

    *PPIX Claims Made Prior Acts Supplemental Application is necessary.
  • StateExpirationLicense #PermanentTemporaryStatus 
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  • Please list all office locations where you currently practice. Use the Remarks Section to list additional locations at which you render professional services.
  • Entity NameAddressCityStateFrom (Mo/Yr)To (Mo/Yr) 
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  • MEDICAL TRAINING AND HISTORY

    If CV is attached, please skip questions #1 and #2
  • HospitalCity/StateFrom (Mo/Yr)To (Mo/Yr) 
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  • HospitalCity/StateFrom (Mo/Yr)To (Mo/Yr) 
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  • HospitalCity/StateFrom (Mo/Yr)To (Mo/Yr) 
    Add a new row
  • HospitalCity/StateFrom (Mo/Yr)To (Mo/Yr) 
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  • Add a new row
  • PRACTICE INFORMATION

  • % of Practice 
    Add a new row
  • Average # of office hours per weekAverage # of patients per weekAverage # of hospital hours per weekAverage # of hospital admissions per year 
    If yes, complete the following questions
  • FacilityCityState% of practiceType (full/active)CourtesyConsultingRestrictedOther 
    Add a new row
    If yes, list the facilities
    If yes, please submit a copy of current certification.
  • Drop files here or
  • If you answer yes to any of the following questions, please give full details in the Remarks Section. Include dates and copies of related documents.
    (If yes, please accompany this application with a letter outlining dates of treatment, results of treatment, and current status. This letter should be from your treating physician or institution).
    (If yes, please accompany this application with a letter outlining dates of treatment, results of treatment, and current status. This letter should be from your treating physician or institution).
  • Drop files here or
    If you answered yes, provide complete details of all open and closed claims/suits/incidents, including those closed with no payments/dismissed and /or discontinued, using the attached Claim Information Form. Copy and complete a separate form for each. You may also upload information relevant to the claim(s)/suit(s)/incident(s) here.
  • PROCEDURES

    NO SURGERY: includes incision of boils, superficial abscesses or suturing of skin and superficial fascia, similar minor procedures of a normal family type practice. Administration of anesthesia by topical or local infiltration. No obstetrical procedures or assisting in surgery.

    MINOR SURGERY: includes the above and general practioners and specialists performing normal vaginal deliveries and assisting in major surgery on their own patients only. Invasive procedures that do not open or enter a major body cavity.

    MAJOR SURGERY: includes the above, minor surgery not included above, assisting in major surgery on other than their own patients, major surgery. Any operation done using general anesthesia including operations in or upon any body cavity.
  • Insurance Carriers

    To assure that there are no gaps in coverage, please list all previous medical professional liability Insurance carried during the past 10 years, beginning with your current carrier. Use the Remarks Section, page 6, to list additional carriers.
  • To (Mo/Yr) 
  • Attach a copy of the Declarations Page from your most recent policy.
  • From (Mo/Yr)To (Mo/Yr) 
  • If your current policy is claims-made and you cancel this policy without purchasing an extended reporting endorsement (tail coverage) from the current carrier, there will be no coverage for any claim from any act or omission that took place during that period of claims-made coverage.

    However, you may apply for coverage with a retroactive date back to the first day of your claims-made policy. A completed PPIX Claims Made Prior Acts Coverage Supplemental Application is necessary.

    Retroactive coverage does not cover current claims that have been filed against you and/or reported to the previous insurer prior to the effective date of the policy with PPIX. Any claims and all conduct, circumstances, or incidents that could reasonable be expected to result in a claim must be reported to your present carrier prior to the requested effective date of this insurance.
  • Authorization

    AGREEMENT: I do hereby warrant the truth of any statements and answers mentioned herein, and that I have not intentionally withheld any information that could influence the judgement of the company in considering this application for professional liability insurance. I hereby acknowledge that I have completed the required reporting of claims and incidents to my current carrier. Erroneous information and/or material misrepresentation will cause immediate rescission of my insurance coverage.

    AGREEMENT: I understand that the policy being applied for does not cover the liability of others that I may have assumed under any contract or agreement. (Note: Your being approved for coverage by the company does not imply acceptance by the company of any contract or agreement or any liability assumed thereunder.)

    AGREEMENT: I understand that in order to underwrite professional liability insurance, the company must have access to all possible information concerning my professional conduct and experience. I hereby authorize and direct any medical society, medical doctor, hospital, residency program, insurance company, inter-indemnity arrangement, underwriter, and insurance agent to furnish any information concerning me or my medical practice that the company may request.

    AGREEMENT: Since I understand that the free exchange of information is essential, I agree that any person or organization furnishing information to the company pursuant to this consent and direction, together with the agent, employees, or officers of such person or organization, will not be liable to me in any way for the furnishing such information.

    AGREEMENT: I agree that in order to maintain insurance coverage I will comply with the Company’s established risk management programs and requirements. Upon acceptance by PPIX this Application will be made a part of any policy issued. Commonwealth of Pennsylvania Fraudulent Insurance Acts: 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 in a crime and subjects such person to criminal and civil penalties.
  • PPIX Supplemental applications are necessary if coverage for Corporations, Partnerships or Associations is desired.

    Edition: 7/1/04
  • This section should be completed if the premium for this insurance is paid by someone other than the Applicant. If the premium for this insurance has been paid and the policy is later cancelled or otherwise changed, any refund of premium that results from such cancellation or change should be assigned to:
  • (employer or other person or entity to whom any refund check should be made payable)
  • The Payor agrees to pay any premium for the professional liability insurance policy applied for and any rene wal or replacement of it. The Applicant for this insurance assigns any and all rights to receive any refund of premium in excess of that earned by Positive Physicians Insurance Exchange for this insurance to the Payor named above. The Applicant appoints Payor or Payor’s successors or assigns as Applicant’s Attorney-in-Fact with full authority to cancel or amend the insurance policy applied for and to execute or receive any document, instrument, payment or notice of any kind relating to the insurance policy, except with respect to giving or withholding consent to settle claim or suit as may be provided in the insurance policy applied for.

    No other interest in the insurance applied for may be assigned by any party without the written consent of Positive Physicians Insurance Exchange.

    This assignment will remain in effect unless both Payor and Applicant agr4ee in writing to its termination.
  • This section should be completed if the Applicant purchases a claims-made policy. If the claims-made professional liability insurance policy is cancelled or non-renewed, the Applicant agrees that the following person or entity is designated as the responsible party for the purchase of a tail policy for the Applicant.
  • The Applicant also agrees and understands that if a tail policy is not purchased upon cancellation or non-renewal of the policy, and prior-acts coverage is not purchased from their next carrier, the Applicant could be considered to be in non-compliance with licensure regulations.
  • Claim Information Form

  • PLEASE READ THE FOLLOWING BEFORE COMPLETEING THE PRIOR ACTS APPLICATION!!!

    Any item reported on the previous page must be reported to your current carrier prior to expiration of your present policy. Additionally, if you have received any requests for records from attorneys or from dissatisfied patients, or if you have received either verbal or written patient complaints about care rendered, these occurrences MUST be reported to your current carrier and recorded on the proceeding page. If these matters are not reported to your current carrier, the chance of an uninsured claim is greatly increased!
  • POSITIVE PHYSICIANS INSURANCE EXCHANGE

    SUPPLEMENTAL APPLICATION – CLAIMS MADE PRIOR ACTS COVERAGE
  • ATTACH A COPY OF THE CURRENT DECLARATION PAGE SHOWING THE RETROACTIVE DATE I hereby represent that I am requesting Claims Made coverage. Except as indicated below, I have no knowledge of any professional liability claims, circumstances, occurrence, incidents or conduct which has been or likely to be asserted against me or any corporation association or partnership for which I am making application, which occurred on or after the requested Retroactive Effective Date.

    Report below any such incidents involving serious injury including, but not limited to: brain injury, unexpected death, blindness (in one or both eyes), significant burns (including overexposure to radiation), significantly diminished life expectancy, injury to the spinal cord, significant sensory and motor loss, or loss of a significant portion of an arm or leg. Please give a brief description of each such claim, occurrence, incident or circumstance.
  • Please note that no coverage will be provided under the applied-for policy, for any such claim, occurrence, incident or circumstance permitted to be reported to your current insurance provider*. (*Insurance Provider includes any self-insurance, or any other financial mechanism, whether public or private, established for the purpose of paying awards, judgments or settlements for loss or damages against insured entitled to participate in such mechanism).

    The above is true to the best of my knowledge, information and belief. I understand that misrepresentations, omissions, concealment of facts, or incorrect statements in this application which are fraudulent, or material either to acceptance of the risk or to any hazard assumed by PPIX. may result in denial of coverage under the applied for insurance for any claims(s) arising therefrom. This application will become part of the policy
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