Application for Ambulatory Surgery Center Facility

Application for Ambulatory Surgery Center Facility

  • Instructions:

    1. Answer ALL questions which are appropriate to your operation completely, leaving no blanks. If any questions, or part thereof, do not apply, state “N/A.” If you need more space for your responses, continue on a separate sheet of your letterhead and indicate question number. When necessary, check all boxes that apply. This form must be completed, dated, and signed by a principal or an officer of the applicant.

    2. Please include the following information with the completed application:
    • Previous insurance company loss runs for the past ten (10) years including current year, ground-up and unlimited, including all selfinsured, insured, and uninsured losses. Full details of allegations on all losses paid or outstanding in excess of $50,000.
    • Current audited financial statement.
    • Brochures, pamphlets or other advertising material utilized by your facility.
    • Copies of any inspection reports/surveys conducted by outside organizations within the past 3 years.
    • For Excess coverage please provide copies of all underlying policies.
    • For Umbrella coverage please provide copies of Primary Declaration pages or COI for all applicable coverages (auto, Employers Liability, etc.). Copy of underlying automobile carrier’s loss run for the past 5 years including the following information: carrier, date of loss, report date, total incurred, status (open or closed), and narrative of claim. Date of loss valuation must be within past ninety days.
    • Start-Up Facility – (1) Business Plan, (2) Curriculum Vitae (CV) of all physicians involved, (3) inspection application(s), (4) loss history (10 years) for each physician involved.

    If you have multiple operations that are not ambulatory surgery centers, please complete Lexington Insurance Company’s general applicant for healthcare facilities.
  • General Information

  • Gross RevenuesYear 
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  • Gross RevenuesYear 
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  • Gross RevenuesYear 
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  • Insurance Coverage Desired

    *Professional Liability and General Liability Limits must be the same, but limits apply separately.
  • Effective DateOcc. or Claims MadeRetro DateLimits of Liability (Per Claim/Aggregate)*Ded or SIR 
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  • Effective DateOcc. or Claims MadeRetro DateLimits of Liability (Per Claim/Aggregate)*Ded or SIR 
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  • Effective DateOcc. or Claims MadeRetro DateLimits of Liability (Per Claim/Aggregate)*Ded or SIR 
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  • Effective DateOcc. or Claims MadeRetro DateLimits of Liability (Per Claim/Aggregate)*Ded or SIR 
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  • Effective DateOcc. or Claims MadeRetro DateLimits of Liability (Per Claim/Aggregate)*Ded or SIR 
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  • Effective DateOcc. or Claims MadeRetro DateLimits of Liability (Per Claim/Aggregate)*Ded or SIR 
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  • Effective DateOcc. or Claims MadeRetro DateLimits of Liability (Per Claim/Aggregate)*Ded or SIR 
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  • Effective DateOcc. or Claims MadeRetro DateLimits of Liability (Per Claim/Aggregate)*Ded or SIR 
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  • Effective DateOcc. or Claims MadeRetro DateLimits of Liability (Per Claim/Aggregate)*Ded or SIR 
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  • DescriptionEffective DateOcc. or Claims MadeRetro DateLimits of Liability (Per Claim/Aggregate)*Ded or SIR 
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    (applies separately to Professional Liability and General Liability)
  • Self-Insured Rentention (SIR)

    List below all subsidiary, controlled entity or LLC that are desired to be added as additional named insured. For each facility/entity, provide date acquired, description of operations, ownership in percentages and retroactive date.
  • SubsidiariesDate AcquiredDescription of Operations% OwnershipRetroactive Date (MM/YY) 
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  • By State (for all locations)#of visits current year#of visits projected 12 months 
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    please specify the number of visits by state. “Visits” are defined as the number of times each patient enters your facility for healthcare related services.
  • Professional Liability Information

  • Number of Outpatient Visits

    Surgical services provided – Indicate the type of procedures and number of outpatient visits for each procedure. “Visits” are defined as the number of times each patient enters your facility for healthcare related services.
  • Visits Prior YearVisits Current YearVisits Projects Next 12 Months 
  • Visits Prior YearVisits Current YearVisits Projects Next 12 Months 
  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Prior YearCurrent YearProjected 12 Months 
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  • Full-timePart-time 
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  • Full-timePart-time 
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  • A proposed physician/surgeon would only be covered under the policy in his/her capacity as a medical director for activities relating to administration of the facility. If a more comprehensive physician/surgeon professional liability coverage is desired, please complete individual physician/ surgeon application.
  • SpecialtyCurrent Insurance Carrier and Policy #Limits of LiabilityEffective date of the policyEmployee/contractorHours/month 
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  • SpecialtyCurrent Insurance Carrier and Policy #Limits of LiabilityEffective date of the policyEmployee/contractorHours/month 
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  • SpecialtyCurrent Insurance Carrier and Policy #Limits of LiabilityEffective date of the policyEmployee/contractorHours/month 
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  • Other Health Care Professionals. Indicate the number in each category, full-time and part-time
  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Employees (Part and Full time)Contractors (Part and Full time)Volunteers (Part and Full time) 
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  • Drop files here or
  • Do you have written requirements that the following providers carry Professional Liability Insurance? Please indicate the limits required.
  • COMMERCIAL GENERAL LIABILITY INFORMATION

  • Address/OccupancySquare FootageAgeType of Construction# of floorsType of Fire Protection 
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    Fire Protection Key: AS = Automation Sprinkler, H = Heat Detector, S = Smoke Detector, A = Automatic Alarm
  • NameAddressInterest 
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  • EMPLOYER’S LIABILITY AND EMPLOYEE BENEFIT LIABILITY INFORMATION

  • OTHER EXPOSURES

  • RISK MANAGEMENT/LOSS CONTROL

  • NameTitlePhone Number 
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  • Section 1 – Accreditation

    “Accredited by the Joint Commission” means the organization is in compliance with all standards at the time of the on-site survey or has successfully addressed requirements for improvement in an Evidence of Standards Compliance (ESC) within 45 days following the survey. The AAAHC awards accreditation for three years when it concludes that the organization is in substantial compliance with the standards. The AAAASF Accreditation Program requires 100% compliance with each AAAASF Standard to become and remain accredited. CARF accreditation for three years: The organization satisfies each of the CARF accreditation conditions and demonstrates substantial conformance to the standards. It is designed and operated to benefit the persons served. The organization demonstrates quality improvement from any previous periods of CARF accreditation.
  • Section 2 - Patient Safety

  • Section 3 — Surgical Fire Prevention

    Wet any gauze or sponges used with uncuffed tracheal tubes to minimize leakage of gases into the oropharynx, and keep them wet.
    Place the electrosurgical pencil in a holster when it is not in active use. If electrosurgical services are not offered, select not applicable.
    Place the laser in standby mode whenever it is not in active use. If laser surgical services are not offered, select not applicable.
  • Section 4 - Credentialing, privileging and Performance Improve

  • Section 5 - Non-Physician Providers

  • Policy and Loss Information

    Please provide past policy information as requested.
  • Carrier or Self InsuredEffective DateOcc. or Claims Made*Retro DateLimit per Occ/AggDed or SIRPremium 
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  • Carrier or Self InsuredEffective DateOcc. or Claims Made*Retro DateLimit per Occ/AggDed or SIRPremium 
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  • Carrier or Self InsuredEffective DateOcc. or Claims Made*Retro DateLimit per Occ/AggDed or SIRPremium 
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  • Carrier or Self InsuredEffective DateOcc. or Claims Made*Retro DateLimit per Occ/AggDed or SIRPremium 
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  • Carrier or Self InsuredEffective DateOcc. or Claims Made*Retro DateLimit per Occ/AggDed or SIRPremium 
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  • Carrier or Self InsuredEffective DateOcc. or Claims Made*Retro DateLimit per Occ/AggDed or SIRPremium 
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  • Carrier or Self InsuredEffective DateOcc. or Claims Made*Retro DateLimit per Occ/AggDed or SIRPremium 
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  • Carrier or Self InsuredEffective DateOcc. or Claims Made*Retro DateLimit per Occ/AggDed or SIRPremium 
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  • Carrier or Self InsuredEffective DateOcc. or Claims Made*Retro DateLimit per Occ/AggDed or SIRPremium 
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