Name of Applicant
Mailing Address
Contact Person
Phone #
Fax #
E-mail Address
1.
If the premium payer is other than the named insured, is this insurance assigned to the payer?
Yes
No
2.
,
hereinafter referred to as The Corporation and
Corporation's Name
,
referred to as the Medical Care Practitioner (MCP), hereby enter into an agreement.
Practitioner's Name
a)
Whereas The Corporation has agreed with the MCP to pay the cost of professional liability coverage for the MCP during the policy term beginning
(date)
, and
b)
Whereas the premiums for professional liability insurance coverage for the MCP may be due and payable in advance for the policy period
Now, therefore, the parties hereto agree to the following:
In consideration for The Corporation paying the premiums for said insurance, the MCP hereby:
1)
Assigns and gives a security interest to The Corporation for any and all unearned premiums which may become payable from the professional liability policies paid for by The Corporation.
2)
Irrevocably appoints The Corporation as the MCP’s Attorney-In-Fact with full authority to cancel the MCP’s professional liability policies purchased by The Corporation, receive all sums assigned to The Corporation or in which the MCP has granted The Corporation a security interest in furtherance of this agreement.
3)
All legal rights given to The Corporation shall benefit The Corporation’s successors and assigns.
4)
The MCP agrees not to further assign any interest in said professional liability policies without The Corporation’s written consent.
Date
Corporation
Medical Care Practitioner
Name of Officer of Corporation
Name of Witness
Address of Corporation