Answer each and every question as it pertains to the practice you need coverage for.
Answer each and every question legibly. When a question is not applicable to your practice, please write N/A. Incomplete answers may cause your application to be returned to you or cause the underwriter to make assumptions that could negatively affect your premium.
Please use the following checklist to ensure that your application is complete. Only complete applications can be submitted for underwriting.
- Include a copy of your Curriculum Vitae.
- Copy claim form as many times as needed. Include loss information from all previous insurance companies. Be sure to explain all previous claims and reported incidents in depth and provide complete information on each and every claim you have ever been involved with.
- Order hard copy loss runs from all prior carriers for underwriting purposes. The loss runs must include expenses and indemnity amounts paid if there were any claims within the past 10 years. (Note: The loss runs must be dated within the last 60 days.)
- Enclose copies of your licenses and specialty board certificates.
- If you desire prior acts coverage (coverage for claims resulting from your practice which occurred before the date this new policy would become effective) please enclose a copy of your current medical malpractice insurance policy declarations page (front page, which lists limits, effective dates, etc.).
- Include copies of licenses for any allied providers working for you (PA’s, RN’s, NP’s, etc.) if appropriate.
- Be sure to sign the attached Broker of Record Letter authorizing us to discuss your insurance with each carrier and place on your letterhead.
- Include a one page narrative on scope of practice outlining any changes in the past few years to practice and any unique or unusual circumstances regarding practice that was not covered in your application.