Medical Legal Defense Program
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Online Policy Application
Questions
1
a)
First Name*
Last Name*
Professional Title*
Email*
Address 1*
Address 2
Town/City*
Postcode/Zip*
County/State*
Phone*
Ext
b)
Are you a current member of the A4M?
Yes
No
c)
Is the applicant a licensed physician?*
Yes
No
d)
In which States is the applicant licensed?*
e)
Does the applicant currently have in force medical malpractice insurance?*
Yes
No
Renewal date?
f)
What is the applicants total billing revenue*
g)
How many patients does the applicant have*
h)
Within the last 6 years, has the applicant been the subject of or involved in any litigation, administrative proceeding, demand letter or formal or informal government investigation or inquiry?*
Yes
No
i)
Within the last 6 years, has the applicant ever been investigated or sanctioned by a state medical licensing board, medical staff, or health plan?*
Yes
No
j)
Within the last 6 years, has the applicant ever been investigated or sanctioned by any local, state or federal government or agency regarding the delivery of health care services or reimbursement thereof?*
Yes
No
k)
Within the last 6 years, has the applicant ever lost any medical practice privileges, other than voluntary termination?*
Yes
No
2
Does the applicant have knowledge or information of any act, error, omission, fact or circumstance that might reasonably be expected to give rise to a claim against him or his or their predecessors in business?*
Yes
No
It is understood and agreed that the applicant's responses to questions have been provided following, and based upon, reasonable inquiry, and that if any information was not disclosed that should have been disclosed, coverage shall be excluded for the applicant for any Claim based upon, arising out of or attributable to, in whole or in part, directly or indirectly, or in any in any way involving the facts or subject matter of such information that was not disclosed.
Other Information
The undersigned declares that to the best of his/her knowledge, the responses, statements and information provided herein are true, accurate and complete, based upon reasonable inquiry. Signing of this Application does not bind the undersigned to complete the insurance, but it is agreed that this Application shall form the basis of the contract should a Policy be issued, and this application will be deemed attached to, and become part of such Certificate, if issued. Underwriters shall be authorized to perform any and all investigations and inquiries in connection with this Application as they may deem necessary.*
Agree
Disagree
It is represented and warranted that the particulars and statements contained in the Application for the proposed Certificate and any materials submitted herewith (which shall be retained on file by Underwriters and which shall be deemed attached hereto, as if physically attached), are the basis for the proposed Certificate and are to be considered as incorporated into, and constituting part of, the proposed Certificate.*
Agree
Disagree
It is agreed that in the event there is any material change in the answers to the questions contained in this Application prior to the effective date of the Certificate, the undersigned or the applicant will promptly notify Underwriters of such material changes and, at the sole discretion of the Underwriters, any outstanding quotations may be modified or withdrawn.*
Agree
Disagree
It is agreed that in the event there is any material misstatement or untruth in the applicant's responses to the questions contained in this Application, Underwriters shall have the right to exclude from coverage any Claim based upon, arising out of or attributable to, in whole or in part, directly or indirectly, or in any in any way involving the facts or subject matter of such material misstatement or untruth.*
Agree
Disagree
Disclaimer
For purposes of creating a binding contract of insurance by this application or in determining the rights and obligations under such contract in any court of law, the parties acknowledge that a signature reproduced by either facsimile or photocopy shall have the same force and effect as an original signature and that the original and any such copies shall be deemed on the same document.
* required field
