SUPPLEMENTAL APPLICATION
Partnership, Professional Associations & Corporations Coverage

  • If a questions does not apply to your practice, state “none” or “N/A” (Not Applicable). This application consists of A) application(s) for insurance, including any additional pages and Claim information form. The complete application, together with any supplementary information, must be signed and dated by the applicant in all spaces indicated. Failure to provide complete information will delay the processing of the application.

    I GENERAL INFORMATION



  • Primary Address/Location



  • List other Practice Addresses: (attach letterhead if necessary)




  • Billing Address Other than Primary Practice


    If you require that your premium billing be sent to an address other than your primary practice address, please indicate.



  • II CORPORATE COVERAGE

  • (you must attach a copy of the most recent Declarations Page from your present carrier indicating the original effective date of coverage.)



  • STAFFING OF PARTNERSHIP, ASSOCIATION OR CORPORATION


    Please identify all employed and contracted individuals and provided information requested.

  • NAME & DEGREE ---- SPECIALTY --- *STATUS ---- % OF OWNERSHIP



  • III LOSS INFORMATION


    List current and previous professional liability insurers with dates for the past 10 years.



  • IV 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 judgment 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 there under.)

    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 Positive Physicians Insurance Exchange, this Application will be made a part of any policy issued.

    Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against any insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

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