As a licensed physician or surgeon, the undersigned hereby makes application for insurance with the above company and in connection with said application hereby furnishes the company with the information that follows or is attached here to:
$100,000 medical incident / $300,000 annual aggregate
Full Prior Acts coverage will be considered subject to any extended reporting Period (tail) coverage of Prior Acts Date on prior insurances. Any Prior Acts extension of coverage is available only to those physicians who have and will combine to practice medicine exclusivity in Louisiana.
If employed physician, provide name/address of employer (if other than as noted above)
NOTE: If you answered yes to any part of the above question and you want to insure these medical professionals under your professional liability policy please type out below their names, category, and years of experience. If such individuals also maintain their own professional liability, please attach copies of certificates of insurance.
Major Surgery includes operation procedures in or upon any body cavity, including cranium, thorax, abdomen, and pelvis; any other operations or procedures which, because of the condition of the patient or the length or circumstances of the operation, present a distinct increase in morbidity and / or mortality.
List in chronological order, with dates and address, all present and past hospital staff appointments. Do not list hospitals which are part of your internships(s) and residency(ies) since you only rotate though these facilities as part of your training.
On submission of this form you understand that the information submitted herein becomes part of the professional liability Application for insurance and all information are true and correct
Please download the Claim/Suit/Compliant Addendum
HERE. Once filled out please attach it below
I hereby declare that all statements and answers herein and provided for consideration of insurance are full, complete, and true to the best of my knowledge and belief and that no material circumstances of information concerning the subject matter of the questions asked has been withheld or omitted. The statements made and information provided is also based on query of Executive Officers (including office manager, human resources manager or compliance manager or their equivalent). I understand that the statements and information provided will be relied upon by insurer, re-insurers and representatives and are material in determining not only whether insurance coverage will be issued or renewed, but also to determine correct classification and premium calculations.
I hereby authorize release my name, business address, policy and premium information by insurer, re-insurer or their representatives or designees. I authorize any professional societies, prior or present business or medical associates, licensing boards, hospitals, government entities, corporations, partnerships, organizations, institutions, or persons that may have any record or knowledge concerning any of the statements and answers made herein to release such information upon its request. I authorize the use of a copy of this authorization in place of the original. I understand that the coverage provided is subject to a program aggregate limit as well as sublimit per certificate holder as per the master policy on file with the Company. Submitting this application does not bind the insurer to issue a policy for acceptance and will be attached thereto and be a part thereof. It is further acknowledged and agreed by the applicant that he/she has received and reviewed a copy of the Operating Agreement of Louisiana Premier Physicians Program, L.L.C., a Louisiana limited liability company operation as a risk purchasing group for the insurance being applied for, and that, upon acceptance of this application, the applicant will become a party to such Operating Agreement and will be a Class A-1 Member of Louisiana Premier Physicians Program, L.L.C. in accordance with and subjects to the terms of such Operating Agreement.
Louisiana Revised Statue 40:1424, provides, in part, the following: B. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison."