Birtwhistle & Livingston: Medical Malpractice Quoteform

For a quick quote, fill out this form. For a firm quotation, fill out the supplemental pages when applicable.




Name of Applicant
Mailing Address
Contact Person
Phone #	Fax #	E-mail Address
Birth Date	Social Security #	License # for primary practice state
Gender of Applicant? Female Male
Applicant's Practice (check all that apply). Physician Surgeon Dentist Podiatrist Other

First Practice Date (post residency, fellowship or military service)

Is applicant in military service or employed full-time by the federal government? Yes No

If applicant served in the military, was this in repayment of a government obligation? Yes No

Medical School
Degree	Year



List all locations where you work. (Mail will be sent to location #1 unless otherwise indicated)

Location 1
Employer/Facility Name
Street Address
City		County
State	Zip	Phone


Location 2
Employer/Facility Name
Street Address
City		County
State	Zip	Phone


Location 3
Employer/Facility Name
Street Address
City		County
State	Zip	Phone

Please indicate, if applicable, total hours worked per week and month at each office location for the following activities.

	Location #1		Location #2		Location #3
Actual patient care, including record keeping and hospital rounds:	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month

Administrative duties:	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month

Surgeries and assists:	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month

House calls and nursing home visits:	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month

Utilization review:	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month

Teaching:	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month	Hrs./Week	Hrs./Month


Total hours worked per week:	Total hrs./Week		Total hrs./Week		Total hrs./Week


Type of Coverage Requested*: Claims-Made Occurrence Occurrence Plus Claims-Made Advantage
*not all coverages available in all states

Is Prior Acts Coverage Requested? Yes No
If yes, please mail a copy of current policy and complete the Prior Acts Supplemental Application.

This application is for? a new policy the renewal of an existing policy a quote
Requested Effective Date
Requested Retroactive Date

Type of Practice: (check all that apply) :
Employee	Independent Contractor
Sole Proprietor/Unincorporated	Principal in a Professional Corporation
Limited Liability Corporation	Partnership
Professional Association	Other

Is coverage desired for your organization? Yes No
If yes, name of organization:

(For associations with more than one member involved, complete Appendix C)

For solo corporations only:
Do you wish to include coverage for your professional corporation or professional association on this policy? Yes No
If yes, name of organization
		Tax ID#
(This organization will share the limit of liability of the individual.)

Name of present insurance carrier

Type of present policy: Occurrence Plus Occurrence Claims-Made
Was tail purchased? Yes No (Mail a copy of prior policy)
(Please mail a copy of prior policy.)

Previous professional liability insurance carrier(s)
Company Name		Policy Number
Coverage Date Effective	Coverage Date Expired
Occurrence/Occurrence Plus/Claims-Made		Retro. Date

Company Name		Policy Number
Coverage Date Effective	Coverage Date Expired
Occurrence/Occurrence Plus/Claims-Made		Retro. Date
(If Tail Coverage was provided, please mail a copy of the Tail Coverage endorsement.)

If you are employed by someone else, please answer the following:
Name of employer
Name of employer's professional liability insurer
(If your employer is to pay the premium for your coverage, refer to Appendix A.)



List below the names of the employees you wish to cover in each area. Please submit by mail, a copy of each employee's license or certificate.

Surgical Assistants/Technicians	Mental Health Counselors
Physicians' Assistants	Physical/Occupational Therapists
CRNA's	Perfusionists
Midwives	Technicians - NOC
Nurse Practitioners/Clinicians	Medical Assistants
Orthopedic Technicians	RN's/LPN's
Psychologists	Social Workers
Physicists	Speech Pathologists/Audiologists
Optometrists	Other (define)



List facilities or organizations where you have practiced or have had staff or courtesy privileges for your profession since graduation.

Company Name and Location		Department
Type of Privileges		Dates: From/To

Company Name and Location		Department
Type of Privileges		Dates: From/To

Company Name and Location		Department
Type of Privileges		Dates: From/To

Upon request from any hospital, certificates of insurance, notices of policy changes and cancellations of insurance will be forwarded.


List all states in which you are licensed or have been licensed and information on that state license if applicable:
State	License #	DEA License #
Active? Yes No	% of Patients	% of Hospital Procedures
% of Income	% of Office Hours

State	License #	DEA License #
Active? Yes No	% of Patients	% of Hospital Procedures
% of Income	% of Office Hours

List all states in which you have practiced (excluding training) within the last five years.


Is coverage desired for your staff? Yes No N/A
Staff Coverage Form

Do you have a position for which no coverage is required, or for which you are insured with another carrier? Yes No
If yes, indicate activity, entity and location to be excluded, and indicate hours worked at this position only.

Has anyone ever brought a claim against you regardless of whether the claim was dismissed or a judgment rendered?

Yes No

(If yes, please complete a Supplemental Claims Application for each claim.)

Do you know of any circumstances, act, error or omission that could possibly result in a professional liability claim against you?

Yes No

Has any health care facility ever denied, restricted, suspended or revoked privileges or has probation been invoked?

Yes No

If yes, give months and years.

Are you currently being treated for a psychiatric condition, alcoholism or substance abuse?

Yes No

Are you suffering from an impairment that is not adequately controlled by treatment?

Yes No

Have you ever been charged with a criminal offense or are your currently under investigation for a criminal act?

Yes No

Has your professional liability coverage ever been cancelled, restricted, non-renewed, or have you withdrawn an application for insurance to avoid declination?

Yes No

Has a complaint ever been submitted to the Board of Medical Examiners or are you currently under investigation by any regulatory body?

Yes No

If you answered yes to any of the above questions, please explain below and mail full documentation from any agency involved.



Professional Liability Limits desired*
$1MM/$3MM $2MM/$4MM $3MM/$5MM $4MM/$6MM $5MM/$7MM $6MM/$8MM
*higher limits available upon request

Your professional specialty:
physician podiatrist dentist other

Please indicate the applicable percentage of your practice (total should equal 100%)
%	Major Surgery - performing major surgery or assisting in major surgery on patients other than your own. (Includes, but is not limited to, tonsillectomies, adenoidectomies, obstetrics, liposuction, procedures requiring general anesthesia or pregnancy terminations:
	% first trimester termination
	% second trimester termination

%	Podiatrists - incision below the subcutaneous layer for the correction of deformity or disease. (Includes, but is not limited to, surgery on ligaments, tendons and bones.) Included in this definition is the removal of lesions which lie below the subcutaneous layer - such as ganglion and neuroma of thoracic, vascular, cardiovascular, or plastic surgery.

%	Minor Surgery - performing minor surgery or assisting in major surgery on your own patients. (Includes, but is not limited to, circumcision, cardiac catheterization (but not pacemaker insertion or Swan-Ganz catheters), needle biopsy for lung, prostrate, colonscopy, upper G.I. endoscopy or laparoscopy.)

%	No Surgery - medical practice which may include incising of boils and abscesses, removal of superficial skin lesions, suturing minor lacerations.

%	Podiatrists - surgery on nails and tissue surrounding the nail, excision of skin lesions which do not lie below the subcutaneous layer.

Medical School	Degree	Year

Residency or Internship	Date of Completion

Fellowship	Date of Completion
Specialty of residency or fellowship	Sub-Specialty
First practice date (post residency, fellowship or military service)

If military service, was this in payment of a government obligation? Yes No

Specialty you currently practice

Are you employed as an Emergency Room physician? Yes No
Are you employed as a Medical Director of any organization? Yes No
Does your employer provide coverage for your Medical Director activities? Yes No

If any of the below activities apply to your specialty, please indicate:
Liposcution	Sigmoidoscopy	Bronchoscopy
Hair Transplants	Intravenous Pyelography	Spinal Surgery
Blepharoplasty	Colonoscopy	Right Heart Catheterization
Mammoplasty	with biopscopy or polyectomy?	Left Heart Catheterization
Abdominoplasty	Vasectomies	Epidural Steroid Injections
Obstetrical Deliveries	Needle biopsy, lung, liver, kidney, prostate (excluding bone marrow)	Invasive cardiac procedures (other than insertion of Swan-Ganz catheters or temporary pacemakers)
Terminations of Pregnancies

List any surgical procedures other than incision of boils, removal or superficial lesions, or suturing of skin:


List any other cosmetic procedures


Indicate percentage of practice involving cosmetic surgery .

Are you board certified by an AMA-approved specialty board? Yes No
Name of Specialty Board		Date of last certification

If you are a foreign medical school graduate, are you certified by the Educational Council for Medical School Graduates?
Yes No

Are you currently an intern, resident or fellow? Yes No
If yes, what is the final date of internship, residency or fellowship?



	I hereby deem that the above information I have supplied is correct, complete and true to the best of my knowledge and has not been falsified in any way, shape or form. I understand that signing this application does not bind Princeton Insurance Company or MIIX Insurance Company to complete the insurance, but it is agreed that this application shall be the basis of a contract should a policy be issued. I authorize the release and exchange of any underwriting or claims information between all prior carriers and the Princeton Insurance Company or the MIIX Insurance Company.

	Name of Applicant
	Date

	Please note that an additional signed form is required by the insurance company.

	NOTICE TO PENNSYLVANIA AND NEW JERSEY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH THE INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO BE SUBJECT SUCH PERSON TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.


	Please note that for a firm quotation you will also need to supply the following items:
	1)	With your application, a short narrative pertinent to any claims with the following information: why you were treating the patient, the allegations, and the medical facts of the case.
	2)	A copy of the Declaration Page of your current policy.
	3)	A copy of your Curriculum Vitae.
	4)	A copy of your Medical License.
	5)	A signed copy of the Authorization to Release Confidential Information form for each insurer you have had in the last five (5) years.