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If previously covered with MedPro RRG, or joining a current MedPro RRGHealthcare Professional group policy, please enter the Policy Number:MEDPRO RRG RISK RETENTION GROUPMULTI-SPECIALTY HEALTHCARE PROFESSIONALPROFESSIONAL LIABILITY INSURANCE APPLICATIONAPPLICATION INSTRUCTIONS1.If additional space is needed, please complete Section X. Supplemental Information with a reference to the question.2.You must apply for coverage for each individual or entity, including any professional corporation, professional association, limited liabilitycompany, business corporation, partnership or joint venture which you are requesting MedPro RRG coverage. Additional documentation may berequested by the Company as necessary. For example: Articles of Incorporation, Declaration Page, copy of your most recent entity professionalliability policy (including all endorsements), etc.3.Please print legibly.4.Please answer all questions; if a question is not applicable, state “N/A”.I. GENERAL INFORMATIONINDIVIDUAL APPLICANTS ONLY: Individuals with a Corporation or Partnership should apply below as a Group Applicant.A.Please check all that apply: Individual Sole Proprietor Individual joining a current MedPro RRG Healthcare Professional Group, Independent Contractor/Self-Employed Employed Practitioner Other, please explain:Corporation or Partnership: Policy Number:B.Name of Individual Applicant (Last Name, First Name, Middle Name, Suffix)C.If we need to contact you for additional information, please indicate the preferred method of contact: Email Address: Phone:-- Fax:--GROUP APPLICANTS/INDIVIDUALS WITH A CORPORATION OR PARTNERSHIP ONLY: Individual Applicants, please skip to Section II.,General Practice Information.A.Please check all that apply: Professional Corporation: sole shareholder Partnership or Professional Association Limited Liability Company (LLC)/Partnership (LLP) Professional Corporation: multiple shareholders Other, please explain:B.Name of Group Applicant/Organization Entity Name (As stated in the Articles of Incorporation.)Federal Tax I.D. NumberState of Incorporation/Date Entity Formed(MM/YYYY)National Provider Number (optional)//Current Entity Retro DateIf claims-made (MM/DD/YYYY)C.If the entity does business under any other name, list additional entity/clinic name(s), Doing Business As (“DBA”), fictitiousname, etc.D. Yes NoIs this entity joining a current MedPro RRG Insured’s Policy?If Yes, please provide the Policy Number: Yes NoE.If you are an owner of the entity identified in Question B. above, do you desire coverage for this entity?If Yes, please select one of the following: Add this entity on a “Shared Limit” basis with the Scheduled Named Insured Providers. (Not available in some states.) Add this entity with an additional “Separate Limit” to my policy for an Additional Charge.F.If this group/entity has a web address, please provide the website address (URL):G.If we need to contact the group/entity for additional information, please indicate the primary contact name and preferredmethod of contact:Primary Contact Name (Last Name, First Name, Middle Name, Suffix) Email Address:HCPG-001-NY Phone:1Title-- Fax:--03/2014
II. GENERAL PRACTICE INFORMATIONA.1.Practice Location(s): (Please list primary location first. Combined percentage of practice for all locations must total 100% and cannot be ofequal values.)Type of Facility: Office Hospital Surgical Center (Accredited Facility) Other, please explain:LOC. #1% of PracticeName of Primary Practice Location (All documents will be mailed to thislocation, unless a different mailing address is requested in Question B. below.)Street Address2.Type of Facility:LOC. #2Suite Office HospitalCityCountyState Surgical Center (Accredited Facility) Other, please explain:% of PracticeName of Practice LocationStreet Address3.Type of Facility:LOC. #3CountySuite Office Hospital% of PracticeCityState Surgical Center (Accredited Facility)Zip Code Other, please explain:Name of Practice LocationStreet AddressB.Zip CodeCountySuiteCityStateZip Code Yes NoDoes the group/entity require a mailing address other than the primary practice location address?If yes, please select one of the following mailing preferences: Billing only All DocumentsIf yes, please provide the Location # or print the different mailing address:Street AddressSuite LOC.# Other, please print below:CityStateZip CodeIII. INDIVIDUAL APPLICANT INFORMATIONIndividual Applicants, please fill out Section 1. only. Group Applicants, please fill out each section for each applicant requestingcoverage. If more than three individual applicants, please use the Individual Applicant Information Supplemental Application.1.Please select your affiliation to the practice: Shareholder Partner Employee Independent Contractor/Self-Employed Faculty//Date of BirthName (Last, First, M.I., Suffix)Percentage of Practice: (Total must equal 100%.)License #StateDegree LOC.#1 Active Inactive Pending/TemporarySpecialty LOC.#2%License #State%2./First Date in Practice (MM/YYYY)Current Prof. Assoc. Membership NameNational Provider Number (Optional)Please select your affiliation to the practice:Percentage of Practice: (Total must equal 100%.)//Current Retro Date (if claims-made)Soc. Security No. (Optional)//Date of BirthDegree LOC.#1%Specialty LOC.#2 Active Inactive Pending/TemporaryState%/Graduation Date (MM/YYYY)/First Date in Practice (MM/YYYY)Current Prof. Assoc. Membership NameNational Provider Number (Optional)2 LOC.#3% Active Inactive Pending/TemporaryLicense #StateIndicate the estimated average hours per week for which you require MedPro RRG coverage.HCPG-001-NYHrs. Shareholder Partner Employee Independent Contractor/Self-Employed FacultyName (Last, First, M.I., Suffix)License #% Active Inactive Pending/TemporaryIndicate the estimated average hours per week for which you require MedPro RRG coverage./Graduation Date (MM/YYYY) LOC.#3Hrs.//Current Retro Date (if claims-made)Soc. Security No. (Optional)03/2014
III. INDIVIDUAL APPLICANT INFORMATION (CONTINUED)3.Please select your affiliation to the practice: Shareholder Partner Employee Independent Contractor/Self-Employed Faculty//Date of BirthName (Last, First, M.I., Suffix)Percentage of Practice: (Total must equal 100%.)License #StateDegree LOC.#1 Active Inactive Pending/Temporary%Specialty LOC.#2License #State% LOC.#3 Active Inactive Pending/TemporaryIndicate the estimated average hours per week for which you require MedPro RRG coverage./Graduation Date (MM/YYYY)/First Date in Practice (MM/YYYY)Current Prof. Assoc. Membership NameNational Provider Number (Optional)%Hrs.//Current Retro Date (if claims-made)Soc. Security No. (Optional)IV. PROFESSIONAL INFORMATION (ATTACH A SEPARATE PIECE OF PAPER, IF NEEDED.)A.Have you, your entity, or any applicant requesting coverage above, or any of your employees, ever been indicted for, chargedwith, or convicted of, any act committed in violation of any law or ordinance other than minor traffic offenses? Yes NoIf yes, please explain:Applicant Name(s):B.Date:/(MM/YYYY)Have you, your entity, or any applicant requesting coverage above, or any of your employees had hospital privileges, DEA/narcotics license, healthcare license or reimbursement privileges refused, denied, revoked, suspended, restricted, subject to a Yes Noreprimand, placed on probation or voluntarily surrendered?If yes, please explain:Applicant Name(s):C.Date:/(MM/YYYY)Have you, your entity or any applicant requesting coverage above or any of your employees ever incurred or become aware ofhaving a condition that impairs your ability to practice your specialty? (i.e. convulsive disorders, mental illness, multiple sclerosis,addiction to alcohol, narcotics, or other controlled substances, etc. Note: Functional addiction is considered a reportable impairment.) Yes NoIf yes, state condition(s), date(s), and identify the treating physician(s) in the space provided below. In the event of any such impairment, astatement from the treating physician attesting to your fitness to practice your specialty must accompany this application.If yes, please explain:Applicant Name(s):Treating Physician(s) Name(s):D.Date:/(MM/YYYY)Have you, your entity, or any applicant requesting coverage above, or any of your employees ever been accused of sexualmisconduct of any kind? Yes NoIf yes, please explain:Applicant Name(s):E.Date:/(MM/YYYY)CALIFORNIA and MISSOURI APPLICANTS: Do NOT answer the following question:Have you, your entity or any applicant requesting coverage ever had any professional liability insurance refused, declined,canceled or non-renewed by an insurance company? Yes NoIf yes, please explain:Applicant Name(s):F./(MM/YYYY)Will you, your entity or any applicant requesting coverage be treating or reviewing treatment of federal prison inmates? Yes NoIf yes, how many hours per week?G.Date:Hrs.Applicant Name(s):Will you, your entity or any applicant requesting coverage be treating non-federal prison inmates?If yes, how many hours per week?HCPG-001-NYHrs. Yes NoApplicant Name(s):303/2014
V. LOSS INFORMATIONPlease complete a Loss Information Supplement for each written request, incident, claim or suit (A, B or C) in which the group,entity and/or individual’s policy was triggered and that has NOT been covered by a MedPro RRG policy.Report all matters related to professional liability, commercial general liability, employment practices liability, cyber liability, business errors andomissions, hired non-owned auto, or any other coverage for which MedPro RRG coverage is being requested, for each applicant (including but notlimited to, board complaints, etc.).For Questions B. and C. below, report all matters that might reasonably lead to a claim or suit being brought against the group, entity, and/oranyone from your practice, even if it is believed the claim or suit would be without merit.A.Has your entity or any individual applicant now, or ever been, involved in a claim or suit arising out of the rendering or failureto render professional services, or related to any other coverage requested from MedPro RRG (e.g. CGL, EPLI, etc.)? Yes NoIf yes, how many?B.Applicant Name(s):Is your entity or any individual applicant from the practice aware of any complication, incident or adverse outcome resulting ininjury or death that might reasonably result in a claim or suit against an applicant, entity or anyone from the practice? Thisincludes, but is not limited to, the following: Yes No Amputation Permanent Neurological Injury Loss of Major Organ Function Death Loss of Vision.If yes, how many?C.Applicant Name(s):In the last 12 months, has your entity, or any individual applicant or anyone from the practice received a written request froman attorney for treatment records concerning any current or former patient(s) which might reasonably result in a claim or suitagainst an applicant, entity or anyone from the practice? Yes NoIf yes, how many?Applicant Name(s):VI. COVERAGE INFORMATIONIf Occurrence Coverage is Desired:A. Coverage desired: Occurrence coverageB.Requested Coverage Effective Date: Annual policy terms will begin and end on the same month and day.From://(MM/DD/YYYY)12:01 AMTo://(MM/DD/YYYY)C.Desired Limits: Per Occurrence/Per Claim Filed: D.List your current professional liability insurer(s) for the last 10 years, or back to your start date of practice. Please explain anygaps in coverage. (Attach a separate piece of paper, if necessary.):Current Insurer:,12:01 AM Occurrence Claims-madeFrom:,Annual Aggregate: //(MM/DD/YYYY)12:01 AMTo:,,//(MM/DD/YYYY)12:01 AMIf Claims-Made Coverage is Desired: If selecting Occurrence coverage above, skip to Extended Reporting Section on the following page.Notes:1. Claims-Made coverage is limited generally to liability for injuries for which claims are first made during the policy period, forservices rendered between the retroactive date and expiration date of the policy. Please contact your agent should you haveany questions pertaining to the differences between Claims-Made and Occurrence coverage or the additional expenseassociated with an “extension contract(s)” or “tail coverage”.2.Requested limits and/or policy types may not be available in all states.A.Coverage desired:B.Requested Coverage Effective Date: Annual policy terms will begin and end on the same month and day.From: Claims-Made without Prior Acts Coverage Claims-Made with Prior Acts Coverage Convertible Claims-Made: Step to Occurrence 4th-yr. if claim free//(MM/DD/YYYY)12:01 AMTo://(MM/DD/YYYY)12:01 AMC.Current Claims-Made policy retroactive date (Date is required for Claims-Made with Prior Acts.):Please attach a copy of your current Declaration Page(s).D.Desired Limits:Per Claim Filed: E.List your current and previous professional liability insurer(s) for the last 10 years, back to your current retroactive date, orstart date of practice. Please explain any gaps in coverage. (Attach a separate piece of paper, if necessary.),,Current Insurer: Occurrence Claims-MadeHCPG-001-NYAnnual Aggregate: From://(MM/DD/YYYY)4,//(MM/DD/YYYY),12:01 AMTo://(MM/DD/YYYY)12:01 AM03/2014
Extended Reporting Section:If “Occurrence” or “Claims-Made coverage without Prior Acts” coverage was selected as the desired coverage, and the most recentprior coverage was issued on a Claims-Made basis, please complete one of the following: An extension contract endorsement (tail coverage) has been or will be purchased. An extension contract endorsement (tail coverage) has not and will not be purchased. I will not purchase tail coverage (reporting endorsement) from my current carrier where I am insured under a Claims-Made policy. I realize thatmy failure to purchase such coverage from my current carrier will result in an uninsured exposure for any claims which may arise as a result ofprofessional services rendered while insured by my current carrier’s policy. I understand that the policy, for which I am applying from The MedicalProtective Company, will not provide Prior Acts coverage.VII. FRAUD NOTICEMANDATORY: ALL APPLICANTS must read and initial the following:Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance orstatement of claim containing any materially false information, or conceals for the purpose of misleading, information concerningany fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not toexceed five thousand dollars and the stated value of the claim for each such violation.VIII. SUBSCRIBER AGREEMENTI understand that if my application for insurance is accepted by MedPro RRG Risk Retention Group (“MEDPRO RRG”), I will be a subscriber(“Subscriber”) of MEDPRO RRG and, by my signature below, I hereby acknowledge and agree that the below provisions of this Section VIII, includingthe Power of Attorney, (“Subscriber Agreement”) constitute the charter of MEDPRO RRG and that the subscribers to MEDPRO RRG from time to timeshall together comprise the reciprocal insurer, which shall operate through its Attorney‑in‑Fact as provided in this Subscriber Agreement as a riskretention group in accordance with federal law and as a risk retention group in the form of a reciprocal captive insurer in accordance with District ofColumbia law.In consideration of similar agreements executed or to be executed by other subscribers and of the benefits of the exchange of such agreements andof the terms of this Subscriber Agreement, I agree to the following terms and conditions.1.Appointment and Powers and Duties of Attorney-In-Fact. Subscriber agrees to the appointment of MedPro Risk Retention Services,Inc., an Indiana corporation ("Attorney-in-Fact"), as the Attorney-in-Fact for MEDPRO RRG to carry out the purposes and objectives setforth in this Subscriber Agreement and to carry out all business on behalf of MEDPRO RRG and the subscribers thereto. Attorney-in-Fact isvested with all necessary power and authority to act on behalf of MEDPRO RRG and the subscribers thereto, including conducting the affairsof MEDPRO RRG, managing and operating (directly or through contract with third parties (including affiliates of Attorney-in-Fact)) MEDPRORRG for the benefit of the subscribers, and causing the issuance and exchange of indemnity, insurance or reinsurance contracts with othersubscribers.2. Limitations of Liability.a. The financial liability of Subscriber shall be limited to the amount of annual premiums on any contracts of indemnity, insurance orreinsurance due from Subscriber, provided, however, that all contracts of indemnity, insurance or reinsurance shall contain a "limit ofliability" and in the event it is determined that Subscriber's liability on a claim under said contract of indemnity, insurance orreinsurance exceeds the limit of liability, such excess amount shall be the sole and complete responsibility of Subscriber.b. Should any suit, legal proceeding or other action be brought against Attorney-in-Fact resulting from or arising out of Subscriber'sobligation on any contract of indemnity, insurance or reinsurance that Subscriber may enter into, then and in that event, any and alljudgments entered against Attorney-in-Fact in that capacity shall be deemed a legal judgment against Subscriber.3. Maintenance and Distribution of Surplus. Attorney-in-Fact shall cause MEDPRO RRG to maintain surplus in an amount sufficient toprovide for the financial integrity of MEDPRO RRG and in an amount satisfactory to the District of Columbia Department of Insurance,Securities and Banking. In no event, however, shall Attorney-in-Fact be required to contribute its own assets or the assets of any affiliate toMEDPRO RRG.a. Subscriber authorizes Attorney-in-Fact to accrue for the benefit of MEDPRO RRG and the subscribers net income and savings realizedfrom the exchange of contracts of indemnity, insurance or reinsurance hereunder and the management of MEDPRO RRG and itsassets.b. Subject to the laws of the District of Columbia, if MEDPRO RRG is dissolved by Attorney-in-Fact, Attorney-in-Fact shall, after the fullsatisfaction of all liabilities and surplus notes of MEDPRO RRG from MEDPRO RRG's assets, pay each subscriber then insured anequitable share of all remaining assets, which payment shall be in full satisfaction of all rights and interests of such subscribers.Amounts to be paid to subscribers shall be distributed on an equitable basis as determined by Attorney-in-Fact.4. Term of Subscriber Agreement.a. This Subscriber Agreement shall have no fixed term and begins with the commencement of the policy period of any contract ofindemnity, insurance or reinsurance issued hereunder to Subscriber and ends upon cancellation or other termination of such contract ofindemnity, insurance or reinsurance or upon replacement of this Subscriber Agreement by a modified subscriber agreement providedby Attorney-in-Fact. The period of subscription shall not include any period of coverage under extended reporting policies or extendedreporting or tail coverage endorsements.b. Subscriber agrees that this Subscriber Agreement is expressly limited to the uses and purposes herein expressed and to no other. ThisSubscriber Agreement may be terminated by Subscriber or by Attorney-in-Fact upon 30 days written notice. The Subscriber'sappointment of Attorney-in-Fact and Subscriber's obligations and authorizations under this Subscriber Agreement shall survive thetermination of this Subscriber Agreement until any and all claims involving the indemnity, insurance or reinsurance contracts of theSubscriber and any and all other matters existing between the Subscriber and MEDPRO RRG, the Attorney-in-Fact or with third partieshave been settled or satisfied. Subscriber agrees that the Attorney-in-Fact shall have the authority and ability to perform all dutiesand carry out all obligations during any extended reporting or tail coverage endorsements during the term of this SubscriberAgreement or after termination.HCPG-001-NY503/2014
c.5.6.7.8.9.After termination of this Subscriber Agreement, Subscriber shall have no rights to participate in any distribution of assets upondissolution of MEDPRO RRG.Replacement of Attorney-in-Fact. Attorney-in-Fact may resign as Attorney-in-Fact upon designation by Attorney-in-Fact of a successorattorney-in-fact and 60 days written notice to existing subscribers. Any such successor attorney-in-fact shall have all the powers, rights andduties provided for in this Subscriber Agreement, and this Subscriber Agreement shall remain in full force and effect with such successorattorney-in-fact.Principal Office. The principal office of MEDPRO RRG shall be maintained in the District of Columbia or at such other place as designatedby Attorney-in-Fact.Limitation of Liability of Attorney-in-Fact. Subscriber agrees that no officer, director, or employee of Attorney-in-Fact shall bepersonally liable to MEDPRO RRG or its subscribers for any breach of duty owed to MEDPRO RRG or its subscribers, provided however thatthis provision shall not relieve an officer, director or employee from liability for any breach of duty based on an act or omission (a) in breachof such person's duty of loyalty to MEDPRO RRG and its subscribers; (b) not done in good faith or involving a knowing violation of law; or(c) resulting in receipt by such person of an improper personal benefit. Such officers, directors and employees of Attorney-in-Fact shall beentitled to indemnification and advancement of expenses subject to the same exceptions recited above.Nature of MEDPRO RRG. Subscriber acknowledges that MEDPRO RRG is a risk retention group organized in the District of Columbia as areciprocal captive insurer and as such its contracts of indemnity, insurance or reinsurance are not subject to all state insurance laws andregulations. Further, state insolvency or guarantee funds are not available to risk retention groups, like MEDPRO RRG. Subscriber alsoacknowledges that MEDPRO RRG is a reciprocal organization under which each subscriber exchanges insurance obligations with the othersubscribers through an attorney-in-fact.Governing Law. This Subscriber Agreement shall be governed by and interpreted according to the laws of the District of Columbia withoutgiving effect to the conflict or choice of law provisions of that or any other jurisdiction.IX. NOTICES AND AGREEMENTSBy my signature, I hereby represent that all applicants have granted me full authority to execute this application on his, her or the entity’s behalf and Iam authorized to represent and sign on behalf of anyone from my practice. I also represent that I have reviewed the responses contained in thisapplication with the applicants, and we are in agreement they are full and complete to the best of our combined knowledge and belief. In addition, Irepresent that I have discussed the representations provided throughout this application with the applicants and that they understand and agree thatsuch representations are binding upon him, her or the entity, even though I am executing this application on the applicants’ behalf.I further acknowledge that the above statements and particulars, or any statements and particulars made in any and all documents, applications,supplemental pages or other attachments (hereinafter "Attachments") for the purposes of my, or any applicants’ initial or renewal application, aretrue and that I, nor any applicant, have not knowingly suppressed or misstated any material facts and I, and any applicant, agree that this application,and any Attachments, shall be the basis of the contract with the Company. I agree to notify the Company if there are any future material changes inany answer to this application, or its Attachments, including without limitation, any change in professional specialty, affiliation or workingarrangement with any other healthcare professional, facility, firm or professional association.I understand that any material misrepresentation or omission made by me or any other applicant on this application may act to render any contract ofinsurance null and void and without effect or provide the Company the right to rescind it. By making this application, I am not, nor is any otherapplicant relying upon any oral or written representation that coverage has or will be extended or that a policy of insurance will be issued.I further understand and agree that I, or any applicant, have no right to demand or expect coverage until the Company has: (1) received thecompleted application(s); (2) offered a premium quote; and (3) received, as a precondition to coverage, the total premium due or, if the Company hasagreed to finance the premium, the first installment due. In addition, I or any applicant understands that if payment of premium or first installment isby check, electronic transfer or money order, it shall not be considered "received" by the Company until it has been honored by the bank.I AGREE THAT IF I, OR ANY APPLICANT, FAIL TO COMPLY WITH THESE TERMS WE WILL HAVE NO COVERAGE FOR ANY CLAIM UNDER ANYPOLICY OF INSURANCE FOR WHICH WE ARE APPLYING.I, or any other applicant, understand that the Company may wish to contact persons, hospitals, schools, employers, insurance agents, professionalliability insurers or other entities to verify and/or ascertain information regarding credentials and background both prior to and if issued, after theissuance of a contract of insurance. Therefore, I hereby instruct any such person, hospital, school, employer, insurance agent, professional liabilityinsurer or other entity to release to the Company any information regarding me or any applicant, which the Company, in good faith, believes to beapplicable and pertinent to this application and if issued, the contract of insurance issued hereunder.By signing this application on behalf of a group, or an entity (which may include a professional corporation, a professional association, a limited liabilitycompany, a general business corporation, a partnership, a joint venture, or a governmental entity), I warrant that I am an Officer, Shareholder,Partner, or other Authorized Representative of the group or entity applying for coverage.I warrant that I am authorized to disclose all information that I may submit or which I may authorize others to submit in connection with thisapplication, including authority to disclose such information under federal and state privacy protection statutes and regulations.Application must be signed by the Individual Applicant, a President, Chief Executive Officer, or other Officer, Shareholder, or Partnerof a PC or PA, or the equivalent Authorized Representative.Authorized Representative/Subscriber’s Signature/TitlePrinted NameAgent/Producer NameLicense NumberHCPG-001-NYDate Signed (MM/DD/YYYY)603/2014
X. SUPPLEMENTAL INFORMATIONHCPG-001-NY703/2014
HCPG-001-NY 1 03/2014 INDIVIDUAL APPLICANTS ONLY: Individuals with a Corporation or Partnership should apply below as a Group Applicant. If previously covered with MedPro RRG, or joining a current MedPro RRG Healthcare Professional group policy, please enter the Policy Number:
