Application for Ambulatory Surgery Center Facility Facility Application Step 1 of 3 33% 1. Name and Mailing Address of Facility:2. AgentContact PersonPhoneFaxEmail Website3. Tax ID4. License No.5. Type of Coverage Claims-Made Occurrence 6. Requested effective date:7. Retroactive date8. Limits of Liability: $1,000,000/$3,000,000 $2,000,000/$4,000,000 9. Number of locations:10. Patient VisitsPast 12 monthsProjected next 12 months11. Gross receipts:Past 12 monthsProjected next 12 months12. Payroll:Past 12 monthsProjected next 12 months 13. Hours of Operation:14. Describe the type of organization and ownership: Professional Association Partnership Corporation For Profit Not for profit Community Clinic Other 15. Are there subsidiaries that are to be included in this coverage? If yes, please provide the name and relationship.16. List all members, partners, or stockholders. Indicate which ones work at the organization and their positions.17. Is coverage desired for staff of this organization? Yes No If yes, complete Appendix A, - Staff schedule of this application If no, are employees required to carry their own coverage? Yes No If yes, will the staff share the limits of insurance with the organization? Yes No If employees maintain their own insurance, at what limits?Do you require proof of insurance? Yes No 18. How long has the organization been in business?YearsMonths19. Has the organization ever been sued or have any claims been made against it? Yes No If yes, attach a copy of insurance company’s loss run(s)File20. Name of the current professional liability insurance carriers:Attach a copy of the declarations page showing, retroactive date, limits of liability, policy period, and endorsements <br><br>File21. Has your professional liability insurance ever been cancelled or non-renewed? Yes No If yes, why and when?22. Are procedures in place for patient transfers to another facility in the even of an emergency: Yes No If yes, please describe: 23. Are medications administered? Yes No If yes, by whom?24. Do you provide any services over the internet? Yes No 25. Do you treat patients from or at a correctional facility: Yes No 26. Are physicians’ services rendered? Yes No If yes, are the physicians? private physicians contracted physicians employed physicians 27. Are you accredited by any nationally recognized accrediting agency? Yes No If yes, please list the agency:If no, explain why the organization didn’t apply or why it was not eligible.28. Are you licensed by the NJ Department of Health and Human Resources: Yes No 29. List names of employed personnel who are certified in CPR or ALCS.30. Does the organization have a written Quality Assurance/Risk Management Program? Yes No 31. Name of designated Risk Manager:Phone32. Does the facility have any non-expendable medical or surgical machines or services that are used for diagnostic or treatment procedures by individual other than members of your organization? Yes No 33. Do you sell or lease any medical equipment or other product in connection with your operation? Yes No If yes, please describe:34. If you lease equipment to others, do you provide maintenance on the equipment? Yes No If yes, please describe:35. Do you participate as a principal investigator for any clinical trials? Yes No If yes, do you follow FDA – approved protocols? Yes No If yes, please explain Signature This section must be completed by all applicants. All of the above information is true to the best of my knowledge and belief. I understand that signing this application does not bind Positive Physicians Insurance Exchange to complete the insurance, but it is agreed that this application shall be the basis of contract should a policy be issued. I authorize release and exchange of any underwriting or claims information between all prior carriers and Positive Physicians Insurance Exchange. I understand that Positive Physicians Insurance Exchange reserves the right to reject any applicant that does not meet its underwriting standards.Signature of ApplicantDateNameThis field is for validation purposes and should be left unchanged.