PPIA APPLICATION
Salutations First Name Last Name MI    


DOB (MM/DD/YYYY) 		           

Clinic Name / Employer
  


Primary Practice Address
   
City
 State
Zip
     


Residence Address
   
City
 State
Zip
      


Work Phone


Fax 		 

Home Phone
     


Number of years at Current Office Location

  
 
If less than 3 years list previous locations and dates
   
  Additional Practice Locations
 % of practice in this location    


Desired Policy Dates		  
  Effective Date Prior Acts (Retroactive) Date


Desired Coverages/Limits
  Professional liability $200,000 per occurrence/$600,000 aggregate
  Professional liability $500,000 per occurrence/$1,500,000 aggregate
  Professional liability $1,000,000 per occurrence/$3,000,000 aggregate
  Other


Medical Training and History
  Medical Specialty Percentage of Practice
  Sub-Specialty Percentage of Practice


Medical Education
 

A: Medical School: Insitution


  
  State
From
To
Completed?
Yes No
 

B: Internship: Insitution


  
  State
From
To
Completed?
Yes No
 

C: Residency: Insitution


Specialty
  
  State
From
To
Completed?
Yes No
 

D: Residency: Insitution

Specialty
  
  State
From
To
Completed?
Yes No


E: Fellowship: Insitution

Specialty
  
State
From
To
Completed?
Yes No
                 
If you are a graduate of a foreign medical school:
  No Yes Are you certified by the Education Council for Foreign Medical Graduates  
  No Yes Have you passed the FLEX  

  Number of hours of continuing education completed within the last year:  
  Number of hours in excess of state requirements:  
  Date and location you began practicing  
      City State  


Medical License Information
State License Number Expiration Date Status


Narcotics/DEA License Number(A representive will contact you for the DEA Number)
  Status


Board Certification Information
Name of Board Certified Date Qualified
 
 
 
 

Has your certification or membership in any medical association/society ever been voluntarily or involuntarily suspended, denied, revoked or restricted in any state? No Yes
 
Has your medical or narcotics license ever been voluntarily or involuntarily suspended, denied, revoked or restricted in any location? No Yes
 
Have you ever been diagnosed with, or treated for, alcoholism, drug addition, or mental or physcial impairment? No Yes
 
Have any fee, professional relations or other complaints been registered against you with any medical association, state licensing authority or hospital? No Yes
 
Have you ever been charged with any criminal activity? No Yes
 
Has any claim or suit for alleged sexual misconduct ever been brought against you? No Yes
 
Have Medicare or Medicaid authorities ever brought charges against you? No Yes


Insurance History
Insurance Company Current Carrier First Prior Carrier Second Prior Carrier
 
         
  Coverage Form Claims-Made
Occurrence		 Claims-Made
Occurrence		 Claims-Made
Occurrence
         
  Policy Period
         
  Limit of Liability per Claim/Aggregate
         
  Deductible or S.I.R and Amount Deductible
Self Insured Retention		 Deductible
Self Insured Retention		 Deductible
Self Insured Retention
         
  Prior Acts Date (Retroactive Date)


If You Are Currenty Insured By A Claims-Made Policy:		  
 
A. Are you obtaining Extended Reporting ("tail") coverage from your current insurance company? 		No Yes
 

B. Is Prior Acts coverage being requested? 		No Yes
    If Yes, Prior Acts effective Date: (please e-mail a copy of your most recent declaration page)
 

C. Has your practice changed significantly in the last five years? 		No Yes
      Explain


NOTE: To prevent possible gaps in your claims-made coverage, either Extended Reporting or Prior Acts coverage should be purchased.


Current Medical Practice

1. How many hours do you practice per week?
  Average number of patients seen per week?

2. Type of Practice: (check all that apply)
  Solo Practitioner
  Partnership Name 
  Group  Name 
  Employee  Of 
  Space Sharing With 
  Independent Contractor For 

3. Do you have hospital privilege? No Yes
Hospital Name City, State, Zip Type of Privilege  
Full Courtesy
Restricted * Other *
  
Full Courtesy
Restricted * Other *
  
Full Courtesy
Restricted * Other *
  
* If No, Restricted or Other, please explain
 

4. Have your hospital privileges ever been suspended, denied, revoked, restricted or otherwise sanctioned?
  No Yes

5. Do you work in the emergency department other than to fulfill requirements for your hospital privileges?
  No Yes

6. Do you perform or assist in any surgical procedure in a non-hospital setting during which general anesthesia is administered?
  No Yes
   
A. Do you follow ASA standards for pre-operative monitoring?
No Yes
   
B. Number of procedures Annually
        Description
   
C. Anesthesia administered by
   
D. Has all anesthesia & emergency equipment including resuscitative devices been tested for Year 2000 compliance?
No Yes

7. Do you perform surgery? (See categories - these lists may not be all inclusive)
 
No Surgery
No Yes
      Incision of boils and superficial abscesses, suturing of skin and superficial fascia, any similar minor procedures encountered in a normal family type practice shall be considered "No Surgery". This includes administration of local or topical anesthesia and circumcision.
 
Minor Surgery
No Yes
      Includes everything listed under the definition "No Surgery," as well as assisting in major surgery, D&C and vasectomies.
 
Major Surgery
No Yes
      Includes operations in or upon any body cavity including but not limited to the cranium, thorax, abdomen or pelvis, or any other operation which because of the condition of the patient or the length or circumstances of the operation presents a distinct hazard to life. It also includes removal of tumors, plastic surgery, tonsillectomies, aednodectomies, cesarean sections and any other operation done using general anesthesia. Also includes the administration of anesthesia other than local or topical.


Please Answer The Following. If you answer "yes" to any question with the asterisks (**), please explain fully.

Do you perform the following procedures?		  
A. Elective cosmetic surgery
No Yes

Percentage of Practice
%
         
Procedures Performed

B. Itinerant surgery
No Yes**
         
Explain

C. Vaginal deliveries
No Yes

Number per year
%

D. Cesarean sections
No Yes

Number per year
%

E. Deliveries outside the hospital
No Yes**
         
Explain

F. Abortions		 No Yes

Percentage of practice
%

G. Neonatology		 No Yes

Percentage of practice
%

H. Professional sports medicine
No Yes**
        Explain

I. Angiography/arteriography/cardiac catheterization
No Yes

J. Experimental procedures
No Yes**
       

Explain

K. Weight-control surgery/drugs
No Yes

Percentage of practice
%

L. Amniocentesis
No Yes

M. Endoscopic retrograde lymphangiography
No Yes

N. Lympphangiography
No Yes

O. Myelography
No Yes

P. Phlebography
No Yes

Q. Pneumoencephalography
No Yes

R. Radiation therapy
No Yes

T. Organ transplants
No Yes

U. Spinal surgery
No Yes

V. Plastic, cosmetic, or reconstructive surgery
No Yes

W. If you are a primary care physician, do you automatically receive the results of tests and consultation/exam reports ordered by the physician/surgeon to whom your patient was referred?
  No Yes-- How quickly do you receive them?
  Have you ever been involved in a malpractice claim or lawsuit, either directly or indirectly? No Yes
    if yes, how many times?
 
Do you have knowledge of any incident or unexpected adverse outcome resulting in injury or death, claim, potential claim or suit in which you may become involved, including without limitation, knowledge of any injury arising out of the rendering or failing to render professional services which may give rise to a claim? No Yes
      if yes, how many?
      if yes, have these been reported to your insurer? No Yes

NO KNOWN CLAIMS DECLARATION:I DECLARE THAT I AM NOT AWARE OF, NOR DO I HAVE ANY KNOWLEDGE OF ANY CLAIM OR INCIDENT, ANY UNREPORTED CONDUCT, OR ANY CIRCUMSTANCES OR OCCURRENCE WHICH COULD REASONABLY BE EXPECTED TO RESULT IN A CLAIM AGAINST ME SUBSEQUENT TO THE DATE OF MY SIGNATURE BELOW THAT I HAVE NOT ALREADY REPORTED TO MY PREVIOUS PREOFESSIONAL LIABLILITY CARRIER AND WHICH I HAVE NOT DISCLOSED ON MY APPLICATION TO PHYSICIANS PROFESSIONAL INDEMNITY ASSOCIATION.
I HAVE REPORTED ALL CLAIMS AND ALL FACTS OR CIRCUMSTANCES THAT COULD GIVE RISE TO A CLAIM TO APPROPRIATE CARRIERS(S) AND UNDERSTAND THAT ALL SUCH KNOWN CLAIMS OR POTENTIAL CLAIMS WILL NOT BE COVERED BY THIS INSURANCE. I ALSO UNDERSTAND THAT THIS INSURANCE DOES NOT APPLY TO ANY OF THE FOLLOWING:

A. ANY INCIDENT OR CLAIM FOR WHICH I HAVE RECEIVED NOTICE OF CLAIM.

B. ANY INCIDENT OR CLAIM FOR WHICH A LEGAL ACTION HAS BEEN FILED AGAINST MY EMPLOYEES OR ME.

C. ANY INCIDENT OR CLAIM UPON WHICH ANY COMPANIES PREVIOUSLY INSURING ME HAVE PREVIOUSLY ESTABLISHED A CLAIM FILE.

D. ANY INCIDENT OR CLAIM ARISING OUT OF ANY FACT, CIRCUMSTANCES, OR SITUATION INDICATING THE POSSIBLITY OF A CLAIM WHICH WAS KNOWN TO ME AS OF THE EFFECTIVE DATE OF INSURANCE FOR WHICH I AM APPLYING.

AUTHORIZATION

I HAVE ANSWERED THE QUESTIONS IN THE APPLICATION TO THE BEST OF MY ABILITY AND DECLARE THAT, TO THE BEST OF MY KNOWLEDGE, THE STATEMENTS SET FORTH HEREIN ARE TRUE AND CORRECT. ANY PERSION WHO KNOWINGLY FILES ANY APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND WHICH MAY ALSO BE PUNISHABLE BY CRIMINAL AND/OR CIVIL PENALTIES.

I also understand that Physicians Professional Indemnity Association may contact persons, hospitals, employers, insurance agents and producers, professional liability insurers, courts or other entities to verify and/or ascertain information regarding amy credentials and background both prior to and if issued, after the issuance of a contract for professional liability insurance. Therefore, I hereby instruct any such person or entity to release to Physicians Professional Indemnity Association any information regarding me, which the Association, in good faith, believers to be applicable and pertinent to this application and if issued, the contract for professional liability insurance hereunder.