Supplemental Application Partnership, Professional Associations & Corporations Coverage

Supplemental Application Partnership, Professional Associations & Corporations Coverage

  • GENERAL INFORMATION

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  • Corporate Coverage

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  • STAFFING OF PARTNERSHIP, ASSOCIATION OR CORPORATION

    Please identify all employed and contracted individuals and provided information requested.
  • Name and DegreeSpecialty*Status% of ownership 
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    STATUS*: Shareholder (S), Partner (P), Employee (E), Independent Contractor (IC)
  • LOSS INFORMATION

  • InsurerPolicy Term 
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  • 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.Upon acceptance by Positive Physicians Insurance Exchange, this Application will be made a part of any policy issued.