PPIX Physician Group Policy Application

Physician Group Policy Application


  • Application for Group Physician Policy 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 on an additional paper. 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 in ink and dated by the applicant in all spaces indicated. Failure to provide complete information will delay the processing of the application.
  • General Information

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

  • Drop files here or
  • Physicians

  • Name/TitleLicense NumberSpecialtyRetroactive Date 
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  • Loss Information

  • InsurerPolicy Term 
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  • (If you answer yes, provide complete details of all open and closed claims/suits/incidents, including those closed with no payments, on the attached Claim Information Form. Copy and complete a separate form for each.)

    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.