Application for Group Physician Policy Step 1 of 2 50% Please print responses in ink, and answer all questions in full. If a questions does not apply to your practice, state “none” or “N/A” (Not Applicable). Please indicate any additional responses. 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 Formal Name/Title of Partnership, Association, Corporation (Attach copy of Articles of Incorporation.)Has name/title changed from the last filing? Yes No If yes, state old name/title(Attach copies of amendments to Articles of Incorporation)List any other names the above entity is doing business as:What is your practice structure? Solo practitioner with Corporation Corporation Partnership Multi-Shareholder Corporation Joint Venture Space sharing Other Corporation License # (if known): MCPrimary Address/LocationStreetBuilding/SuiteCityStateZip CodeCountyNumber of years at this location% of practicePrimary Practice Office PhoneFaxPractice Web Site Address:Email List other Practice Addresses: (attach letterhead if necessary)StreetBuilding/SuiteCityStateZip CodeCountyNumber of years at this location% of practiceFile 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.StreetBuilding/SuiteCityStateZip CodeII GROUP COVERAGERequested effective date of coverageIf you currently have claims-made coverage will you purchase an extended reporting endorsement (tail coverage) from your current carrier? Yes No If no, do you wish to purchase retroactive coverage from Positive Physicians Insurance Exchange? Yes No Desired Retroactive Date (date policy converted from occurrence to claims made(you must attach a copy of the most recent Declarations Page from your present carrier indicating the original effective date of coverage.)FileAre you, as of this date, aware of any conduct, circumstances, or incidents that occurred during the period of claims made coverage that could reasonable be expected to result in a claim, and that has not been reported to your present or prior insurer(s)? Yes No III PHYSICIANS Please identify all physicians for whom you seek coverage. A separate application should be completed for each physician in addition to this application. NAME/TITLE ---- LICENSE NUMBER --- SPECIALTY --- RETROACTIVE DATE IV LOSS INFORMATION List current and previous professional liability insurers with dates for the past 10 years.InsurerPolicy TermInsurerPolicy TermInsurerPolicy TermHas the entity been involved in a malpractice claim/suit/ incident in the past 10 years? Yes No If yes, how manyIf you answer yes, provide complete details of all open and closed claims/suits/incidents, including those closed with no payments)V 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. 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. 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.Applicant NameAuthorized SignatureDatePhoneThis field is for validation purposes and should be left unchanged.