Application Declaration


  • Commonwealth of Pennsylvania County of
  • an applicant for professional medical liability insurance with Physicians Insurance Program Exchange (PIPE) in Pennsylvania, declare that:
  • 2. The hours I have declared include all aspects of my practice of medicine including, but not restricted to, office hours, surgery and hospital rounds.

    3. Office hours to include not only those services provided by me directly but those services provided by an employee, (such as Nurse Anesthetist, Licensed Practical Nurse, Nurse Midwife, Nurse Practitioner, Occupational Therapist, Physical Therapist, Physician Assistant, Registered Nurse, Aesthetician), or an independent contractor.

    4. I agree to inform my insurance agent, and/or PIPE, of any change in the number of hours I will work each week.

    5. I understand that to misrepresent the number of hours I work each week, or to fail to inform my agent and/or PIPE of a change in my weekly hours, constitutes fraud and that, as a result, my policy can be cancelled or voided.

    6. In the event of litigation, the undersigned agrees to submit his/her patient records and appointment records as part of PIPE’s audit. In the event you cannot prove part time hours, your claim will be denied.
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