St Thomas University Collaborative Practice Agreement PMHNP Report

SOLUTION AT Academic Writers Bay

Collaborative Practice Agreement PMHNP This agreement sets forth the terms of the Collaborative Practice Agreement between Type Name, Degree, and Title, Credentials and Doctor you are collaborating with at Clinic Location. This agreement shall take effect as of Click or tap to enter a date.. Type Name and Credentials meets the qualifications and practice requirements as stated in Section 464.012, F.S., holds a Florida State license and is currently in good standing a certified family psychiatric/mental health nurse practitioner pursuant to Section 464.012 of the Florida Statute and herein meets the requirement of maintaining a collaborative practice agreement with Doctor you are collaborating with a duly licensed and currently registered physician in good standing under Chapter 458.313, Florida Statute. I. Nature of the Practice This collaborative agreement is to establish and maintain a practice model in which the ARNP will provide health care services under the general supervision of Doctor you are collaborating with. This practice shall encompass family psychiatric/mental health practice and shall focus on health screening and supervision, wellness and health education and counseling, and the treatment of common health problems. A. Conditions for which therapy may be initiated include, but are not limited to: 1. The NP is authorized to provide psychiatric and medical care under this collaborative practice agreement (CPA) in all outpatient office locations of above agency, and to any contracting agencies. 2. An NP, who is board certified as a family psychiatric/mental health nurse practitioner, is licensed to provide psychiatric and limited medical care, as defined by the ANA scope of practice to adult, geriatric and pediatric populations. 3. The NP is authorized to provide the following medical functions. (NOTE: This is sample language only to assist the practitioners in discussing and writing the medical functions authorized. Practicing outside the scope of a CPA is a basis for discipline. The CPA should provide authorization for the specific medical acts the NP will be performing.) a. Provides psychiatric diagnostic evaluations to assess for and determine psychiatric illness. Diagnoses that can be made include but are not limited to mood and anxiety disorders, psychotic disorders, disruptive behavior, developmental disorders, eating disorders, delirium and dementia, substance use disorders and personality disorders. b. Request and interpret lab and other diagnostic procedures, such as EKGs, to rule out medical etiology for psychiatric illness or other medical conditions; and to assist in diagnosis, and monitoring for adverse effects from medications. c. Request assessments/evaluations, as needed, to confirm or support diagnoses, or guide treatment, including but not limited to psychological and educational testing; speech/language, vision, and hearing assessment; neurological evaluation; or referral to their primary care physician. d. Prescriptive Authority. i. Drug categories that may and may not be prescribed by the NP (including controlled (II-V), legend, and over the counter drugs) are listed in A. ii. May prescribe drugs commonly used in psychiatry following accepted standards of practice as recommended by either the American Psychiatric Association or the American Association of Child and Adolescent Psychiatry. These drugs may be prescribed “off label” (without FDA approval) if it is an accepted standard of practice. iii. May only prescribe drugs for consumers being served above agency or any contracting agencies iv. May provide pharmaceutical samples to consumers. e. Provide on call coverage when scheduled. f. Provide education to the consumer as indicated about psychiatric illness and, medication (including adverse effects). g. Obtain consultation from the collaborating psychiatrist for complicated illnesses perceived by the NP to be beyond one’s knowledge and skills. h. Provide follow up services to consumers after surgical implantation of a vagal nerve stimulator, including computerized adjustment of device, to provide optimal response. i. The NP may refer a consumer’s care to the psychiatrist if the NP feels the case exceeds the NP’s scope of practice which was part of their graduate curriculum. 4. The NP does not have the legal authority to involuntarily commit a person to inpatient psychiatric treatment. 5. Plan for Emergency Services a. In the event of a life-threatening medical or psychiatric emergency, the consumer is informed to call 911 or to present to the local hospital emergency room. For an urgent need, a provider is available on call 24 hours, seven days per week through the agency emergency phone line. B. The practice of a registered professional nurse as a nurse practitioner may include the diagnosis of illness and physical conditions and the performance of therapeutic and corrective measures including prescribing medications for patients whose conditions fall within the authorized scope of the practice as identified on the college certificate. This privilege includes the prescribing of all controlled substances under a DEA number. The nurse practitioner, as a registered nurse, may also diagnose and treat human responses to actual or potential health problems through such services as case finding, health counseling, health teaching, and provision of care supportive to or restorative of life and well-being. This practice will take place at Clinic location or in such other facility or location as designated by Clinic Name or by the parties of this contract. II. Physician Consultation The physician shall provide general supervision for routine health care and management of common health problems, and provide consultation and/or accept referrals for complex health problems. The physician shall be available by telephone or by other communication device when not physically available on the premises. If the physician is not available, his associate, Name of Associate MD, title, Florida license number/DEA #999999), will serve as backup for consultation, collaboration and/or referral purposes. III. Record Review A representative sample of patient records shall be reviewed by the collaborating physician every three months to evaluate that Your name, NP’s practice is congruent with the above identified practice protocol documents and texts. Summarized results of this review will be signed by both parties and shall be maintained in the nurse practitioner’s practice site for possible regulatory agency review. Consent forms for such review will be obtained from any patient whose primary physician is other than Physician name. IV. Education and Certification Requirements for Registration as a Nurse Practitioner The following items will be maintained and available on site for the Nurse Practitioner: 1. Proof of RN licensure (current RN licensure status may be verified at FBON). 2. Proof of current registration. 3. Proof of current approval to practice. 4. Proof of current national certification. 5. Proof of a current DEA number. 6. A copy of the collaborative practice agreement. 7. The nurse practitioner will maintain documentation of completing 50 contact hours each year of AMA or ANCC approved continuing education courses. V. Resolution of Disagreements Disagreement between Your name and credentials, and Physician name and credentials regarding a patient’s health management that falls within the scope of practice of both parties will be resolved by a consensus agreement in accordance with current medical and nursing peer literature consultation. In case of disagreements that cannot be resolved in this manner, Physician name opinion will prevail. In disagreements between the nurse practitioner and non-collaborating physicians, the collaborating physician’s opinion will prevail. VI. Alteration of Agreement The collaborative practice agreement shall be reviewed at least annually and may be amended in writing in a document signed by both parties and attached to the collaborative practice agreement. VII. Agreement Having read and understood the full contents of this document, the parties hereto agree to be bound by its terms. Student’s information: Physician’s information Signature: ______________________ Signature: ______________________ Printed Name: Printed Name: License # License # Date: Date: ANCC CERTIFICATION APPLICATION FORM EPAYMENT Last Name First Name MI Home Address City State Home Phone Zip/Postal Code Country Personal E-mail Employer Name Social Security Number or Certification Number (if known) Personal Check/Money Order (payable to ANCC) Amount Enclosed:____________________________________ Credit Card Amount to Be Charged:________________________________ Check here if this is an ATM/debit card. See authorization below.* Promotional Code (if applicable):_________________________ Account Number Exp. Date Print Name on Card Signature *ATM/debit card users only: I understand and agree that, by using an ATM/debit card, I am authorizing ANCC to debit my account for the amount specified above. Further, I understand and agree that if the ATM/debit transaction fails or is declined, I am authorizing ANCC to complete the transaction as a credit card charge, if possible. SUBMISSION INSTRUCTIONS Print legibly using either black or blue ink. Keep a photocopy of your application for your records. Submit an application, copy of RN license, and payment. If your state does not issue a paper license, you should include a printout from your state board of nursing’s online verification system. Remember to attach all required supporting documents. Please select one method to submit your application. Mail American Nurses Credentialing Center 8515 Georgia Avenue Suite #400 Silver Spring, MD 20910 ATTN: CERTIFICATION APPLICATION Fax your completed application and any supporting documentation to (301) 628-5004. E-Mail your completed application and any supporting documentation to [email protected] 1 | ANCC Certification Application Form April 20, 2018 ANCC CERTIFICATION APPLICATION FORM Staff use only: cE cP c NE DTInterimAppApril2018 EGENERAL INFORMATION Use your legal name on the application. This name must match photo identification used for examination entry and will be the name printed on your certificate. Last Name First Name Maiden or Other Past Legal Names MI Social Security Number Home Address City State Home Phone Home Fax Zip/Postal Code Country Personal E-mail Employer Name Employer Address City State Work Phone Work Fax Zip/Postal Code Country Work E-mail I am applying for the following ANCC Certification: _______________________________________________ I have practiced the equivalent of two years full time as a nurse. I completed a minimum of 2,000 hours of specialty practice in nursing within the last three years. TYPE OF PRIMARY POSITION (CHECK ALL THAT APPLY): Nurse Manager Educator Clinical/Staff Nurse Nurse Practitioner Researcher Consultant Administrator/DON/CNO/VP Nursing Clinical Nurse Specialist Other: _________________________ Associate/Assistant Administrator ESPECIAL ACCOMMODATIONS/AMERICANS WITH DISABILITIES Check here if you have a disability as defined by the Americans with Disabilities Act (ADA) and require a special accommodation. Please call 1.800.284.2378 for instructions or visit: www.nursingworld.org/certification/certification-policies/special-accommodations 2 | ANCC Certification Application Form April 20, 2018 EPROFESSIONAL DEVELOPMENT RECORD INSTRUCTIONS Use this form to document 30 continuing education hours in this certification’s speciality. Keep copies of continuing education certificates for your records in case you are audited. Examples: in-services, academic credits, CME credits, independent study that has been approved for continuing education, and continuing nursing education related to this certification speciality. If course titles do not clearly reflect the course’s relevance to this certification specialty, include a brief description of how the course relates to this certification specialty. Candidate’s Name (Last, First, MI) EQUIVALENCIES: Social Security Number 1 contact hour = 60 minutes 1 contact hour = 0.1 CEU 1 CME = 60 minutes or 1 contact hour 1 academic semester hour = 15 contact hours 1 CEU = 10 contact hours 1 academic quarter hour = 12.5 contact hours Course Title: If the title does not clearly reflect the content, provide a brief description Name of Sponsor, Provider or Institution Date of Offering Number of Contact Hours Total 30 contact hours required 3 | ANCC Certification Application Form April 20, 2018 EEDUCATION EDUCATION (CHECK ALL THAT APPLY): Diploma Associate Degree in Nursing Associate Degree in Other Field Baccalaureate in Nursing Baccalaureate in Other Field Master’s in Nursing Master’s in Other Field PhD in Nursing PhD in Other Field EdD DNP DNSc ND Other: ______________________ Please list all degrees you have been awarded with the most recent degree first (do not include high school). Attach additional page if necessary. School Name Major/Area of Study Date and Degree Conferred School Name Major/Area of Study Date and Degree Conferred ELICENSURE INFORMATION All candidates must complete this section in its entirety. Required : Attach a copy of license. If your state does not issue a paper license, you should include a printout from your state board of nursing’s online verification system. Check this box if your RN license is not from a state or territory of the United States Current RN License Number State/Country Expiration Date (month/date/year) ESTATEMENT OF UNDERSTANDING I hereby apply for certification offered by the American Nurses Credentialing Center (ANCC). I have read the eligibility criteria for certification. I understand that I am subject to all eligibility requirements for certification as described in this application and that eligibility for certification depends on successfully completing specified certification program requirements. If certified, my name will be included in the official listing of certified nurses. By signing below, I authorize ANCC staff and the Commission on Certification to make whatever inquiries and investigations that they, in their sole discretion, deem necessary to verify my credentials, education preparation, practice, professional standing, and any other information included in, submitted with, or necessary for review of this application. I expressly acknowledge and agree that information accumulated by ANCC through the certification process may be used for statistical, research, and evaluation purposes and that ANCC may enter into agreements to release anonymous and aggregate data to schools or external researchers. Otherwise, subject to the mailing list authorization, all information will be kept confidential and shall not be used for any other purposes without my permission. I hereby certify that the information provided on and with this application is true, complete, and correct. I further attest, by my signature, that I will maintain an active registered nurse license throughout the entire certification period, including all renewal periods. I understand that any misstatement of material fact submitted on, with, or in furtherance of this application for certification shall be sufficient cause for ANCC to: bar me from taking this and future ANCC certification examinations; invalidate the results of my examination; withhold this or other ANCC certifications; revoke this or other ANCC certifications; and take other action against me, including but not limited to notifying licensing authorities, law enforcement agencies, and employers. I further understand that if my certification record is audited, I will be required to submit documentation to support the information in my application. I further understand that if I fail to timely submit supporting documentation, ANCC can: bar me from taking this and future ANCC certification examinations; invalidate the results of my examination; revoke this or other ANCC certifications; and take other action against me, including but not limited to notifying licensing authorities, law enforcement agencies, and employers. (Applications received without a signature incur a delay in processing which will cause a delay in the review of your application and ability to take a certification examination.) Required Signature 4 | ANCC Certification Application Form Print Name Date April 20, 2018 EMAILING LIST REFUSAL ANCC may release mailing lists from its certification database to organizations or individuals who have information to distribute that would be beneficial to nurses or to nursing and credentialing research. If you do not wish your name and mailing address to be released for marketing purposes, please mark the decline option below. I do not wish my name and mailing address to be released for any marketing purposes. This space left intentionally blank 5 | ANCC Certification Application Form April 20, 2018 AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD -FNP AGNP INITIAL CERTIFICATION FNP / AGNP INITIAL CERTIFICATION BY EXAMINATION PAPER APPLICATION Important Information: • • • • • • • • Applicants may apply online to take the national certification examination at www.aanpcert.org Application forms can be downloaded for candidates who are unable to complete the application process via the AANPCB web-based certification system A non-refundable Paper Application Processing Fee is automatically charged for all paper applications, regardless of delivery method (email, mail, and fax) to AANPCB Incomplete applications will result in processing delays There is no charge for receipt of documents or RN license faxed, emailed, or mailed Month & Day of Birth and last 4 numbers of Social Security Number are required to process all applications Name on this application MUST MATCH 2 FORMS OF LEGAL ID required for admittance to the Testing Center, must match legal name used for certification purposes, and is the name that will be printed on the certificate and wallet card issued Refer to the checklist at the end of this application prior to submitting your application For Office Use I am applying for the following examination: ☐ ☐ Family Nurse Practitioner Adult-Gerontology Primary Care Nurse Practitioner PLEASE PRINT NEATLY. Unique Identifiers are established for all applicants. The month and day of your birth, and last four numbers of the applicant’s Social Security Number are required to process all applications. Legal given name must match the identification used for verification and admittance to the testing center. Month & Day of Birth (mm/dd): Last 4 of SSN: AANPCB Certification # (begins with A , F, or AG) if applicable: AANP Membership # (if applicable): Name- First: Middle: Last: Previous Name: Address: City: Phone: Home State: Cell Zip: Work Email Address: INITIAL CERT 01.01.17 WWW.AANPCERT.ORG 1 AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD CURRENT RN LICENSURE -FNP AGNP INITIAL CERTIFICATION (May be accessed from your SBON online verification system) State RN License Number Date Of Expiration PRIMARY CARE NURSE PRACTITIONER PROGRAM DESCRIPTION Degree: Specialty: Dual Program: Graduate Program: ⎕ MSN ⎕ DNP ⎕ Post-Graduate ⎕ No ⎕ Yes If Yes, specify: ⎕ Family NP ⎕ Adult-Gerontology Primary Care NP University: Program Address: Name of Program Director: Program Director’s Contact Phone: Date Program was/ or will be completed: Date Degree was/ or will be conferred: Program is accredited by the following organization: Month Day Year Month Day Year ⎕ CCNE ⎕ ACEN If Post-Graduate candidate, please provide information on graduate degree & date awarded: APRN PRIMARY CARE CORE COURSES Important: If the advanced physiology/pathophysiology, advanced pharmacology, and advanced health assessment coursework was completed prior to 1999 and is not listed as three (3) separate graduate level courses on the applicant’s transcript, the applicant will need to provide a letter from the NP Program Director indicating completion or integration of these courses. Didactic Course Number Number of Credit Hours Year Taken Advanced Pathophysiology Advanced Pharmacology Advanced Health Assessment Primary Care Course Primary Care Course Primary Care Course INITIAL CERT 01.01.17 WWW.AANPCERT.ORG 2 AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD -FNP AGNP INITIAL CERTIFICATION PRIMARY CARE CLINICAL SITE INFORMATION Total Number of Faculty-Supervised Clinical Clock Hours you had, or will have, upon completion of the NP Program (minimum 500): Site Name Address City State Zip Site Specialty Preceptor’s Name including Credentials Site Name Address City State Zip Site Specialty Preceptor’s Name including Credentials Site Name Address City State Zip Site Specialty Preceptor’s Name including Credentials Site Name Address City State Zip Site Specialty Preceptor’s Name including Credentials ATTESTATION STATEMENT FOR CERTIFICATION EXAMINATION I certify that all the information provided on all pages of this Certification Application are true and correct. I further understand that timely submission of all supporting or required documentation, including applicable fees, is necessary for processing my application and failure to respond to a request for further information may result in a delay in taking the National Certification Examination. I acknowledge that I have accessed the AANPCB Candidate Handbook online at www.aanpcert.org and accept all policies as outlined in the Handbook. I also understand that all information I provide will be kept confidential and shall not be used for other purposes without my permission. Signature: INITIAL CERT 01.01.17 Date: WWW.AANPCERT.ORG 3 STATE BOARD OF NURSING NOTIFICATION FORM 1. 2. 3. 4. AANPCB does not charge a verification fee to send status results to State Boards of Nursing. Download this form and save to your computer, then enter and re-save your information before returning to AANPCB Return completed SBON Notification Forms to AANPCB via fax, mail, or email. Please print clearly. State Boards of Nursing may request notification of Certification, Failure, or Expiration Status. APPLICANTS APPLYING FOR INITIAL CERTIFICATION ⎕ Notify the following SBON that I am Eligible-To-Sit for the following AANPCB examination. ⎕ Adult-Gero Primary Care NP Exam ⎕ Emergency NP Exam ⎕ Family NP Exam ⎕ Notify the following SBON that I have taken the AANPCB Certification Examination as soon as my Certification status is released. ⎕ Adult-Gero Primary Care NP Exam ⎕ Emergency NP Exam ⎕ Family NP Exam NURSE PRACTITIONERS CURRENTLY CERTIFIED BY AANPCB ⎕ Notify the following State Board of Nursing of the Status of my current AANPCB National Certification. ⎕ Adult NP ⎕ Adult-Gero Primary Care NP ⎕ Emergency NP ⎕ Family NP ⎕ Gerontologic NP ⎕ Notify the following State Board of Nursing of the Renewal of my AANPCB National Certification. ⎕ Adult NP ⎕ Adult-Gero Primary Care NP ⎕ Emergency NP ⎕ Family NP ⎕ Gerontologic NP My AANPCB Certification Number is (begins with A, AG, E, F, or G): STATE BOARD OF NURSING (SBON) INFORMATION Name of SBON: Address: City: State: Zip Code: City: State: Zip Code: Last 4 of SSN: MM/DD of Birth (e.g.; 01/23): Note: CANDIDATE/CERTIFICANT INFORMATION Full Name: Address: Signature: BONForm.08302017 Main: (512) 637-0500 Fax: (512) 637-0540 Date: www.aanpcert.org [email protected] Toll-free: (855) 822-6727 PO Box 12926, Austin, TX 78711-2926 AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD -FNP AGNP INITIAL CERTIFICATION CERTIFICATION EXAMINATION FEE* ⎕ $290.00 $365.00 AANP Members Non-AANP Members ⎕ TOTAL: $ *Fee includes a nonrefundable administrative paper application fee. Fees are subject to change without notice. ⎕ Enclosed is my check payable to: American Academy of Nurse Practitioners Certification Board (AANPCB ) Check #: Charge my credit card: Money Order #: ⎕ Visa Name on Credit Card (Please print): ⎕ MasterCard ⎕ Amex Card # ⎕ Discover Expiration Date: Signature: ⎕ Check here if you would like to receive information from the American Association of Nurse Practitioners (AANP) Membership Organization including, but not limited to, CE opportunities, health care policy information, National Conference information, and additional beneficial information for Nurse Practitioners. APPLICATION CHECKLIST ⎕ Application form is completely filled out, signed & dated ⎕ Program Description and Primary Care course information filled out completely Transcript shows evidence of the 3 Ps (advanced pathophysiology, advanced pharmacology, and advanced health assessment) as 3 separate courses. If not, a letter from the NP program director has been requested. Clinical clock hours filled in (must be equal to or greater than 500 clinical clock hours) ⎕ ⎕ ⎕ ⎕ Name on application MUST MATCH 2 FORMS OF LEGAL ID required for admittance to the Testing Center Name on application matches legal name used for certification purposes ⎕ Practice site and preceptor information filled out completely ⎕ Official Final Transcript(s)/Post-Graduate Certificate requested ⎕ Copy of current RN license includes expiration date ⎕ Fee payment attached (check) or credit card information completed Update and maintain Online Profile for status updates and communication regarding this application and for further correspondence from the certification program Keep a photocopy of completed application for your records ⎕ ⎕ ⎕ State Board of Nursing Form is completed and attached if required Fax or email completed paper applications, RN licenses, and correspondence to: (512) 637-0540 [email protected] Certification Administration phone numbers: Main: (512) 637-0500 Applications and RN licenses may be mailed to AANPCB at: Capitol Station, LBJ Building PO Box 12926 For overnight delivery to AANPCB: 2600 Via Fortuna, Suite 240 Austin, TX 78746 INITIAL CERT 01.01.17 WWW.AANPCERT.ORG Toll: (855) 822-6727 Austin, TX 78711-2926 4 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 2 If previously covered with Medical Protective, please enter Fax or Mail Completed Application To: CM&F Group, Inc. the policy number ________________________________ 99 Hudson Street, 12th Floor New York, New York 10013-2815 (212)233-8911 (800)221-4904 Fax (646)390.5163 [email protected] THe MedICal ProTeCTIve CoMPaNY (a Stock Company) HealTHCare ProFeSSIoNal – ProFeSSIoNal lIabIlITY INSuraNCe aPPlICaTIoN – NP I. General Information Please print legibly. Please answer all questions; if a question is not applicable, state “N/a”. a. ____________________________________________________________________________________________________________________ Middle Initial __________________ Degree (DNP/MA) ________ Suffix Last Name _____ / _____ / __________ ___________________________________ Date of Birth MM/DD/YYYY e First Name Professional License Number _________________ Graduation Year ____________________________ ______________________ Street Address Apartment/Suite # City ________________________ ______ State Zip Code _____________________ State of Practice _______________________________________ National Provider Identifier # (Optional) ______-______-_______ Business Fax _______-______-________ Residence/Cell Phone rP ______-_____-_______ Business Phone _____________ ra County ct ic ____________________________________________________________ E-mail Address: ____________________________________________________________________________ b. requested effective date: _____ /_____ /______ MM DD YYYY Fo II. Coverage Information *Please note that requested policy types may not be available in all states. a. Coverage desired: ___ Occurrence coverage ___ Claims-Made coverage without Prior Acts coverage PleaSe Call For More INForMaTIoN ___ Claims-Made coverage with Prior Acts coverage PleaSe Call For More INForMaTIoN ___ Convertible Claims-Made coverage PleaSe Call For More INForMaTIoN b. retroactive date shown on my current Claims-Made policy is: (This date is not a requirement for Occurrence or Claims-Made without Prior acts policies.) ____ / _____ / ______ MM DD YYYY C. If “occurrence” or “Claims-Made coverage without Prior acts coverage” was selected as the desired coverage and the most recent prior coverage was issued on a Claims-Made basis, please complete one of the following: __ An extended reporting endorsement (tail coverage) has been purchased. __ An extended reporting endorsement has not and will not be purchased. * Please be advised that if you do not purchase tail coverage (an extended reporting endorsement) from your current insurer where you are insured under a Claims-Made policy, this will result in an uninsured exposure for any claims which may arise as a result of professional services rendered or which should have been rendered while insured by your current insurer’s NP-APP-001-00 PAGE 1 OF 8 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 3 policy. If you do not purchase tail coverage from your current insurer, understand that the policy for which you are applying with The Medical Protective Company, if offered, will not provide prior acts coverage. Claims-Made coverage is limited generally to liability for injuries for which claims are first made during the policy period, for services rendered between the retroactive date and expiration date of the policy. Please contact your agent should you have any questions pertaining to the differences between Claims-Made and occurrence coverage. d. desired limits: * Please note that requested limits options may not be available in your state. __ $100,000/$300,000 __ $200,000/$600,000 __ $250,000/$750,00 __$500,000/$1,000,000 __ $1,000,000/$3,000,000 __ $1,000,000/$6,000,00 __$2,000,000/$6,000,000 __ va only: The limits of insurance for Insureds practicing in Virginia will equal the annual damages cap, as set out in VA Code Ann.§ 8.01-581.15 as amended, based upon the expiration date of the policy to which this application may become attached. __ Yes __ No F. are you a louisiana resident electing to participate in the louisiana Patient Compensation Fund? If yes, coverage provided will have limits of $100,000/$300,000. __ Yes __ No e e. are you an Indiana resident electing to participate in the Indiana Patient Compensation Fund? If yes, coverage provided will have limits of $250,000/$750,000. ct ic G. If in Maryland, do you want to purchase administrative hearing coverage? __ Yes __ No Administrative Hearing Expense Coverage Option: $25,000 each limit/$100,000 aggregate limit. Defense arising out of Disciplinary, Licensure or similar Administrative Proceedings, arising from your professional services as a Healthcare Professional to a patient may be purchased for an additional premium. III. Practice Information N1: Dermatology ra a. Please indicate your Nurse Practitioner rating Class: (Please select all that are applicable. at least one must be selected.) Geriatric Women’s Health Care Oncology Gynecology Psychiatric Care N3: Family Practice N4: Acute Critical Care Pediatric School Nurse OB/GYN Fo N2: rP Correctional Facility 10 Hours / Week NS: Students currently attending an accredited Nurse Practitioner Program * I understand that if I am a Nurse Anesthetist or Certified Nurse Midwife, I am not covered by this policy. b. If your specialty is ob/GYN, are you responsible for the labor or delivery of a fetus? __ Yes __ No __ N/A C. do you perform any major invasive surgical procedures? __ Yes __ No If yes, please give a general description: ______________________________________________________________________________ d. as a Nurse Practitioner I practice as: ___ Employee (W2 & not owner) ___ Self-Employed (File 1099 Tax Form) e. Indicate the estimated average number of hours you practice per week. _______________ F. Is your professional designation/certification currently valid? __ Yes __ No Please provide date of most recent certification: ___ / ___ / _____ MM G. Highest level of education: NP-APP-001-00 __ Masters (MS) DD YYYY __ doctorate (dNP) PAGE 2 OF 8 __ licensed Nurse Midwife 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 4 H. Have you completed training/education courses in addition to the level required for licensing/certification? If yes, please provide details. _________________________________________________________________________________________ I. If you are a student, what is the anticipated date of graduation? ___ /___ /______ MM J. are you a member of a Professional association(s)? DD YYYY __ Yes __ No If yes, please list membership affiliation(s) ____________________________________________________________________________ K. Have you completed a risk management education course within the last (12) months? __ Yes __ No Iv. additional Practice Information a. Have you ever been indicted for, charged with, or convicted of, any act committed in violation of any law or ordinance other than traffic offenses? __ Yes __ No If yes, please attach a separate sheet with full particulars including date(s). b. Have you ever had your hospital privileges, dea license, healthcare license or reimbursement privileges, refused, denied, revoked, suspended, restricted, subject to a reprimand, placed on probation or voluntarily surrendered? __ Yes __ No e If yes, please attach a separate sheet with full particulars including date(s). ic C. Has any professional liability insurance company ever declined, refused, canceled or non-renewed your coverage? NoTe: MISSourI aNd CalIForNIa reSIdeNTS do NoT reSPoNd. __ Yes __ No If yes, please indicate the date(s) and explain: Date ____ /_____ _______________________________________________________ MM YYYY ct d. Have you ever been accused of sexual misconduct of any kind? If yes, please indicate the date(s) and explain: Date ___ /_____ ______________________________________________________ YYYY ra MM __ Yes __ No v. loss Information rP e. Have you ever incurred or become aware of having a condition that impairs your ability to practice your medical specialty? (i.e. convulsive disorders, mental illness, multiple sclerosis, addiction to alcohol, narcotics or other controlled substances, etc). __ Yes __ No * If yes, please complete Medical Condition Supplement Fo Please complete the loss Information Supplement for each written request, incident, claim or suit that has NoT been covered by a Medical Protective policy. Report professional liability and malpractice-related matters, including but not limited 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 you even if you believe the claim or suit would be without merit. a. are you now, or have you ever been, involved in a claim, or suit, received a written request for treatment records arising out of the rendering or failure to render professional services, or related to any other coverage you are requesting from Medical Protective (e.g. CGL, EPLI, etc.)? __ Yes __ No If yes, how many? ______ b. are you aware of any complication, incident or adverse outcome resulting in injury or death that might reasonably result in a claim or suit against you? __ Yes __ No This includes, but it is not limited to, the following: ◊ amputation ◊ Permanent Neurological Injury ◊ loss of Major organ Function ◊ death ◊ loss of vision. If yes, how many? _______ C. In the last 12 months, have you received a written request from an attorney for treatment records concerning any current or former patient(s) which might reasonably result in a claim or suit against you? __ Yes __ No If yes, how many? _______ NP-APP-001-00 PAGE 3 OF 8 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 5 vI. Professional liability Coverage a. Please list your prior professional liability insurance, if any. Coverage Type Insurance Carrier (Occurrence or Claims-Made) Policy Number Limits Effective Date(s) Retro Date __________________ _________________________ _____________________ ___________ _______________ _____________ vII. Important Notice – representations, authorizations, releases and Notices MaNdaTorY: ALL APPLICANTS must read the following unless in a state listed below: 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, which may include voiding of the policy if allowed by state law. ALL ALABAMA APPLICANTS: e Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. ic ALL ARKANSAS APPLICANTS: ct 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. ALL COLORADO APPLICANTS: rP ra It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulated Agencies. ALL DISTRICT OF COLUMBIA APPLICANTS: Fo It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. ALL FLORIDA APPLICANTS: Any person who knowingly, and with intent to injure, defraud, or deceive any insurance company, files a statement of a claim containing false, incomplete or misleading information is guilty of a felony of the third degree. ALL GEORGIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. ALL HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. ALL KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. ALL MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. NP-APP-001-00 PAGE 4 OF 8 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 6 ALL MINNESOTA APPLICANTS: No oral or written misrepresentation made by the insured, or in the insured’s behalf, in the negotiation of insurance, shall be deemed material, or defeat or avoid the policy, or prevent its attaching, unless made with intent to deceive and defraud, or unless the matter misrepresented increases the risk of loss. ALL NEW HAMPSHIRE APPLICANTS: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud as provided in Section 638.20. ALL NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. ALL NEW MEXICO APPLICANTS: 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 civil fines and criminal penalties. ALL OHIO APPLICANTS: e Any person who, with intent to defraud or knowing that he is facilitating a fraud against and insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. ic ALL OKLAHOMA APPLICANTS: ct Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. ALL OREGON APPLICANTS: ALL PENNSYLVANIA APPLICANTS: ra Any person who knowingly files an application for insurance or a statement of a claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, may have committed a fraudulent insurance act, which may be a crime and also punishable by criminal and/or civil penalties in certain jurisdictions. rP 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. Fo ALL RHODE ISLAND APPLICANTS: 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. ALL TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. ALL VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. ALL VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, or denial of insurance benefits. ALL WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, or denial of insurance benefits. ALL WEST VIRGINIA APPLICANTS: 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. NP-APP-001-00 PAGE 5 OF 8 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 7 vIII. Notes and agreements 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 s (hereinafter “s”) for the purposes of my initial or renewal application, are true and that I have not knowingly suppressed or misstated any material facts and I or any applicant agree that this application, and any s, shall be the bases of the contract with the Company. I agree to notify the Company if there are any future material changes in any answer to this application, or its s, including without limitation, any change in professional specialty, affiliation or working arrangement with any other healthcare provider, facility, firm or professional association. Where allowed by state law, I understand that any material misrepresentation or omission made by me on this application may act to render any contract of insurance null and without effect or provide the Company with the right to rescind it. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. If arizona: e I understand that, to the extent permitted by law, the Company reserves the right to deny coverage for any claim submitted under this policy if I have made misrepresentations, omissions, or incorrect statements, or if I have concealed facts that are: (1) fraudulent; (2) material either to the acceptance of the risk or to the hazard assumed by the Company; and (3) the Company in good faith would either not have issued the policy, or would not have issued the policy in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the Company as required either by this application for the policy, subsequent notice, or otherwise. If delaware: If Georgia: ra ct ic Misrepresentations, omissions, concealment of facts and incorrect statements shall not prevent a recovery under the policy or contract unless either: (1) Fraudulent; or (2) Material either to the acceptance of the risk or to the hazard assumed by the insurer; or (3) The insurer in good faith would either not have issued the policy or contract, or would not have issued it at the same premium rate or would not have issued a policy or contract in as large an amount or would not have provided coverage with respect to the hazard resulting in the loss if the true facts had been made known to the insurer as required either by the application for the policy or contract or otherwise. If Kansas: Fo rP I understand that any material misrepresentation or omission made by me on this application may provide the Company with the right to cancel the policy and/or deny coverage for any claim submitted under this policy if I have made misrepresentations, omissions, or incorrect statements, or if I have concealed facts that are: (1) fraudulent; (2) material either to the acceptance of the risk or to the hazard assumed by the Company; and (3) the Company in good faith would either not have issued the policy, or would not have issued the policy in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the Company as required either by this application for the policy, subsequent notice, or otherwise. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. An insurer shall not be required to provide coverage or pay any claim involving a fraudulent insurance act. A fraudulent insurance act is committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto. If Maine: I understand that any material misrepresentation or omission made by me on this application may cause coverage to be cancelled and/or denied. However, we maintain the right to request a ruling from the Maine Courts on voidance or rescission of this policy. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. If New Hampshire: I understand that any material misrepresentation or omission made by me on this application may provide the Company with the right to cancel my policy pursuant to state law and pursue further legal action against me. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. NP-APP-001-00 PAGE 6 OF 8 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 8 If oklahoma: I understand that any material misrepresentation or omission made by me on this application may act to render any contract of insurance null and without effect or provide the Company with the right to rescind it. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. If vermont: Where allowed by state law, I understand that any material misrepresentation or omission made by me or any other applicant on this application may act to render any contract of insurance null and void and without effect or provide the Company the right to cancel it. By making this application, I am not, nor is any other applicant relying upon any oral or written representation that coverage has or will be extended or that a policy of insurance will be issued. If Washington: I understand that any intentional concealment or material misrepresentation made by me, or someone acting on my behalf, on this application may act to render any contract of insurance null and without effect. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. e I further understand and agree that I have no right to demand or expect coverage until the company has: (1) received my completed application; (2) my application has been accepted by the Company; and (3) received, as a precondition to coverage, the total premium due or, if the Company has agreed to finance the premium, the first installment due. In addition, I understand that if I pay my premium or first installment by check, electronic transfer, credit card payment or money order, it shall not be considered as “received” by the company until it has been honored by the bank. If Illinois: ct ic I further understand and agree that I have no right to demand or expect coverage until the Company has: (1) received my completed application; (2) offered me a premium quote; and (3) received, as a precondition to coverage, the total premium due or, if the Company has agreed to finance the premium, the first installment due. In addition, I understand that if I pay my premium or first installment by check, electronic transfer or money order, my policy shall not be deemed to have been issued or delivered and shall not be applicable to any matter which may have been covered under the policy if the payment is later dishonored by the bank. ra I agree that if I fail to comply with these terms I will have no coverage for any claim under any policy of insurance for which I am applying. If California: rP I understand that if I cancel or terminate any coverage that may be provided by the Company, earned premium shall be computed in accordance with the standard short rate tables and procedures with a maximum penalty of up to 11%. Premium adjustments shall be made within a reasonable period of time after cancellation or termination. However, payment or tender of unearned premium shall not be a condition of cancellation. Fo I also understand that the Company may wish to contact persons, hospitals, schools, employers, insurance agents, professional liability insurers or other entities to verify and/or ascertain information regarding my credentials and background both prior to and if issued, after the issuance of a contract of insurance. Therefore, I hereby instruct any such person, hospital, school, employer, insurance agent, professional liability insurer or other entity to release to the company any information regarding me, which the Company, in good faith, believes to be applicable and pertinent to this application and if issued, the contract of insurance issued hereunder. The Delaware Civil Union & Equality Act of 2011 The Medical Protective Company recognizes the rights afforded to individuals under The Delaware Civil Union & Equality Act of 2011 including the following: Parties to a civil union shall have all of the same rights, protections and benefits, and shall be subject to the same responsibilities, obligations and duties, under Delaware law as are granted to, enjoyed by, or imposed upon married spouses. A party to a civil union shall be included in any definition or use of the terms “dependent”, “family”, “husband and wife”, “immediate family”, “next of kin”, “spouse”, “stepparent”, “tenants by the entirety”, and other terms, whether or not gender-specific, that denote a spousal relationship or a person in a spousal relationship, as those terms are used throughout Delaware law. For all purposes of Delaware laws that refer to marriage or marital status, other than Chapter 1 of Title 13 of the Delaware Code, parties to a civil union will be included in such reference. The Act automatically recognizes as civil unions for all purposes of Delaware law legal unions between two persons of the same sex, such as civil unions, marriages and domestic partnerships that are validly formed in jurisdictions other than Delaware and are substantially similar to Delaware civil unions. NP-APP-001-00 PAGE 7 OF 8 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 9 Compliance with Illinois Bulletin 2011-06 and The Religious Freedom Protection and Civil Union Act The Medical Protective Company recognizes the rights afforded to individuals under The Religious Freedom Protection and Civil Union Act which states: “The parties to a civil union are entitled to the same legal obligations, responsibilities, protections and benefits that are afforded or recognized by the laws of Illinois to spouses. The law further provides that a party to a civil union shall be included in any definition or use of the terms “spouse,” “family,” “immediate family,” “dependent,” “next of kin,” and other terms descriptive of spousal relationships as those terms are used throughout Illinois law. This includes the terms “marriage” or “married.” or variations thereon. If policies of insurance provide coverage for children, the children of civil unions must also be provided coverage. The Act also requires recognition of civil unions or same sex civil unions or marriages legally entered into in other jurisdictions.” NOTICE CONCERNING POLICYHOLDER RIGHTS IN AN INSOLVENCY UNDER THE MINNESOTA INSURANCE GUARANTY ASSOCIATION LAW The financial strength of your insurer is one of the most important things for you to consider when determining from whom to purchase a property or liability insurance policy. It is your best assurance that you will receive the protection for which you purchased the policy. If your insurer becomes insolvent, you may have protection from the Minnesota Insurance Guaranty Association as described below but to the extent that your policy is not protected by the Minnesota Insurance Guaranty Association or if it exceeds the guaranty association’s limits, you will only have the assets, if any, of the insolvent insurer to satisfy your claim. ic e Residents of Minnesota who purchase property and casualty or liability insurance from insurance companies licensed to do business in Minnesota are protected, SUBJECT TO LIMITS AND EXCLUSIONS, in the event the insurer becomes insolvent. This protection is provided by the Minnesota Insurance Guaranty Association. ct Minnesota Insurance Guaranty Association 7600 Parklawn Ave # 460 Edina, MN 55435-5137 (952) 831-1908 rP ra The maximum amount that the Minnesota Insurance Guaranty Association will pay in regard to a claim under all policies issued by the same insurer is limited to $300,000. This limit does not apply to workers’ compensation insurance. Protection by the guaranty association is subject to other substantial limitations and exclusions. If your claim exceeds the guaranty association’s limits, you may still recover a part or all of that amount from the proceeds from the liquidation of the insolvent insurer, if any exist. Funds to pay claims may not be immediately available. The guaranty association assesses insurers licensed to sell property and casualty or liability insurance in Minnesota after the insolvency occurs. Claims are paid from the assessment. Fo THE PROTECTION PROVIDED BY THE GUARANTY ASSOCIATION IS NOT A SUBSTITUTE FOR USING CARE IN SELECTING INSURANCE COMPANIES THAT ARE WELL MANAGED AND FINANCIALLY STABLE. IN SELECTING AN INSURANCE COMPANY OR POLICY, YOU SHOULD NOT RELY ON PROTECTION BY THE GUARANTY ASSOCIATION. THIS NOTICE IS REQUIRED BY MINNESOTA STATE LAW TO ADVISE POLICYHOLDERS OF PROPERTY AND CASUALTY INSURANCE POLICIES OF THEIR RIGHTS IN THE EVENT THEIR INSURANCE CARRIER BECOMES INSOLVENT. THIS NOTICE IN NO WAY IMPLIES THAT THE COMPANY CURRENTLY HAS ANY TYPE OF FINANCIAL PROBLEMS. ALL PROPERTY AND CASUALTY INSURANCE POLICIES ARE REQUIRED TO PROVIDE THIS NOTICE. ___________________________________________________________ Applicant’s Signature Date Signed: ____ / ____ / ______ MM DD YYYY ___________________________________________________________ Print Name Agent Name & License Number (if applicable): _____________________________________________________________________________ FL Applicants: Richard J.J. Sullivan, Jr., Non-Resident License #A257825 NP-APP-001-00 PAGE 8 OF 8 02/12 NP BNDL COV 6.26.14_Layout 1 6/26/14 9:08 AM Page 1 NP Secure ® Malpractice Insurance For Nurse Practitioners For nearly 100 years, CM&F has partnered with the country’s strongest insurers for the most comprehensive coverages available. This Occurrence Form Insurance Policy is underwritten by America’s foremost healthcare malpractice insurer – The Medical Protective Company [MedPro], a member of the Warren Buffett/Berkshire Hathaway group of businesses. MedPro enjoys an A++ financial strength rating from the A. M. Best Company. With our combined resources and expertise, we have forged a commitment to support our clients with the challenges which they might face by providing sound protection – today, tomorrow and beyond. Coverage Summary COVERAGES For Fastest Coverage, Apply Online Today! www.CMFGroup.com Need Help? Have A Question About Coverage? Call Us At 1-800-221-4904 Or Email Us At [email protected] Professional Liability Included Workplace/Premises Liability Included General Liability Available Good Samaritan Included Employment Practices Liability Available Assault Upon You $25,000 First Aid $15,000 Medical Payments $25,000/$100,000 Deposition Fees $10,000 License Defense $25,000/$100,000 Sexual Misconduct $25,000 Loss Of Earnings $2,500 Per Day /$35,000 Aggregate HIPAA Defense $25,000 Biomedical Defense $10,000 NURSE PRACTITIONERS FLORIDA ANNUAL RATE TABLES OCCURRENCE COVERAGE FULL TIME PRACTICE RATES (MORE THAN 10 HOURS PER WEEK) CLASS N1 LIMIT SELF EMPLOYED OCCURRENCE $1,000,000 / $6,000,000 $ $ $ $ $ $ CLASS N2 SELF EMPLOYED $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 LIMIT 2,665.00 2,873.00 2,955.00 3,206.00 3,998.00 4,165.00 OCCURRENCE $1,000,000 / $6,000,000 $ $ $ $ $ $ CLASS N3 SELF EMPLOYED $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 LIMIT 3,769.00 4,063.00 4,180.00 4,534.00 5,654.00 5,891.00 OCCURRENCE $1,000,000 / $6,000,000 $ $ $ $ $ $ CLASS N4 SELF EMPLOYED $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 OCCURRENCE $ $ $ $ $ $ $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 5,981.00 6,448.00 6,633.00 7,195.00 8,972.00 9,348.00 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 $ $ $ $ $ $ $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 Nurse Practitioner Rating Classes 2,058.00 2,219.00 2,282.00 2,476.00 3,087.00 3,217.00 EMPLOYED OCCURRENCE $ $ $ $ $ $ 2,910.00 3,137.00 3,227.00 3,501.00 4,365.00 4,548.00 EMPLOYED OCCURRENCE $ $ $ $ $ $ CLASS N4 LIMIT N1: Specializing in Dermatology, Geriatric, 176.00 190.00 195.00 212.00 264.00 275.00 OCCURRENCE CLASS N3 LIMIT FULL TIME $ $ $ $ $ $ EMPLOYED CLASS N2 OCCURRENCE CLASS NS LIMIT 4,871.00 5,251.00 5,402.00 5,860.00 7,307.00 7,613.00 CLASS N1 3,760.00 4,053.00 4,170.00 4,523.00 5,640.00 5,877.00 EMPLOYED OCCURRENCE $ $ $ $ $ $ 4,612.00 4,972.00 5,115.00 5,548.00 6,918.00 7,209.00 Women’s Health Care, Oncology, Gynecology, or Correctional Facility 10 hours/week NS: Students currently attending an accredited Nurse Practitioner Program NURSE PRACTITIONERS FLORIDA ANNUAL RATE TABLES OCCURRENCE COVERAGE PART TIME PRACTICE RATES (10 HOURS OR LESS PER WEEK) CLASS N1 LIMIT SELF EMPLOYED OCCURRENCE $1,000,000 / $6,000,000 $ $ $ $ $ $ CLASS N2 SELF EMPLOYED $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 LIMIT 1,333.00 1,437.00 1,478.00 1,603.00 1,999.00 2,083.00 OCCURRENCE $1,000,000 / $6,000,000 $ $ $ $ $ $ CLASS N3 SELF EMPLOYED $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 LIMIT 1,885.00 2,032.00 2,090.00 2,267.00 2,827.00 2,946.00 OCCURRENCE $1,000,000 / $6,000,000 $ $ $ $ $ $ CLASS N4 SELF EMPLOYED $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 2,436.00 2,626.00 2,701.00 2,930.00 3,654.00 3,807.00 OCCURRENCE $ $ $ $ $ $ 2,991.00 3,224.00 3,317.00 3,598.00 4,486.00 4,674.00 CLASS N1 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 EMPLOYED OCCURRENCE $ $ $ $ $ $ CLASS N2 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 EMPLOYED OCCURRENCE $ $ $ $ $ $ CLASS N3 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 1,455.00 1,569.00 1,614.00 1,751.00 2,183.00 2,274.00 EMPLOYED OCCURRENCE $ $ $ $ $ $ CLASS N4 LIMIT 1,029.00 1,110.00 1,141.00 1,238.00 1,544.00 1,609.00 1,880.00 2,027.00 2,085.00 2,262.00 2,820.00 2,939.00 EMPLOYED OCCURRENCE $ $ $ $ $ $ 2,306.00 2,486.00 2,558.00 2,774.00 3,459.00 3,605.00 Nurse Practitioner Rating Classes N1: Specializing in Dermatology, Geriatric, Women’s Health Care, Oncology, Gynecology, or Correctional Facility 10 hours/week NURSE PRACTITIONERS FLORIDA ANNUAL RATE TABLES CLAIMS MADE COVERAGE FULL TIME PRACTICE RATES (MORE THAN 10 HOURS PER WEEK) CLASS N1 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N2 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N3 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N4 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 1st Year SELF EMPLOYED 2nd Year 3rd Year $ 852.00 $ 1,519.00 $ 918.00 $ 1,637.00 $ 945.00 $ 1,685.00 $ 1,025.00 $ 1,827.00 $ 1,278.00 $ 2,279.00 $ 1,332.00 $ 2,374.00 1st Year $ $ $ $ $ $ 1,205.00 1,299.00 1,336.00 1,450.00 1,808.00 1,883.00 1st Year $ $ $ $ $ $ 1,558.00 1,680.00 1,728.00 1,874.00 2,337.00 2,435.00 1st Year $ $ $ $ $ $ 1,912.00 2,061.00 2,120.00 2,300.00 2,868.00 2,988.00 $ $ $ $ $ $ 2,052.00 2,212.00 2,276.00 2,469.00 3,078.00 3,207.00 EMPLOYED 4th Year $ $ $ $ $ $ SELF EMPLOYED 2nd Year 3rd Year $ $ $ $ $ $ 2,150.00 2,318.00 2,384.00 2,586.00 3,225.00 3,360.00 $ $ $ $ $ $ 2,903.00 3,129.00 3,219.00 3,492.00 4,355.00 4,537.00 2,777.00 2,994.00 3,080.00 3,341.00 4,166.00 4,340.00 $ $ $ $ $ $ 3,752.00 4,045.00 4,161.00 4,514.00 5,628.00 5,864.00 3,410.00 3,676.00 3,782.00 4,102.00 5,115.00 5,330.00 $ $ $ $ $ $ 4,607.00 4,966.00 5,109.00 5,542.00 6,911.00 7,201.00 2,638.00 2,844.00 2,926.00 3,174.00 3,957.00 4,123.00 1st Year $ 658.00 $ 709.00 $ 730.00 $ 792.00 $ 987.00 $ 1,028.00 2nd Year $ $ $ $ $ $ 1,173.00 1,264.00 1,301.00 1,411.00 1,760.00 1,833.00 3rd Year $ $ $ $ $ $ 1,585.00 1,709.00 1,758.00 1,907.00 2,378.00 2,477.00 4th Year $ $ $ $ $ $ 1,727.00 1,862.00 1,915.00 2,078.00 2,591.00 2,699.00 5th Year $ $ $ $ $ $ 2,037.00 2,196.00 2,259.00 2,451.00 3,056.00 3,184.00 EMPLOYED $ $ $ $ $ $ 3,165.00 3,412.00 3,510.00 3,807.00 4,748.00 4,947.00 5th Year $ $ $ $ $ $ 3,732.00 4,023.00 4,139.00 4,490.00 5,598.00 5,833.00 1st Year $ $ $ $ $ $ 931.00 1,004.00 1,032.00 1,120.00 1,397.00 1,455.00 2nd Year $ $ $ $ $ $ 1,659.00 1,788.00 1,840.00 1,996.00 2,489.00 2,593.00 3rd Year $ $ $ $ $ $ 2,241.00 2,416.00 2,485.00 2,696.00 3,362.00 3,503.00 4th Year $ $ $ $ $ $ 2,443.00 2,634.00 2,709.00 2,939.00 3,665.00 3,818.00 5th Year $ $ $ $ $ $ 2,881.00 3,106.00 3,195.00 3,466.00 4,322.00 4,503.00 EMPLOYED 4th Year $ $ $ $ $ $ SELF EMPLOYED 2nd Year 3rd Year $ $ $ $ $ $ $ $ $ $ $ $ 4th Year SELF EMPLOYED 2nd Year 3rd Year $ $ $ $ $ $ 2,237.00 2,411.00 2,481.00 2,691.00 3,356.00 3,496.00 5th Year 4,089.00 4,408.00 4,535.00 4,919.00 6,134.00 6,391.00 5th Year $ $ $ $ $ $ 4,822.00 5,198.00 5,348.00 5,801.00 7,233.00 7,537.00 1st Year $ $ $ $ $ $ 1,202.00 1,296.00 1,333.00 1,446.00 1,803.00 1,879.00 2nd Year $ $ $ $ $ $ 2,144.00 2,311.00 2,378.00 2,579.00 3,216.00 3,351.00 3rd Year $ $ $ $ $ $ 2,896.00 3,122.00 3,212.00 3,484.00 4,344.00 4,526.00 4th Year $ $ $ $ $ $ 3,156.00 3,402.00 3,500.00 3,797.00 4,734.00 4,933.00 5th Year $ $ $ $ $ $ 3,722.00 4,012.00 4,128.00 4,478.00 5,583.00 5,817.00 EMPLOYED 4th Year $ $ $ $ $ $ 5,021.00 5,413.00 5,568.00 6,040.00 7,532.00 7,848.00 5th Year $ $ $ $ $ $ 5,921.00 6,383.00 6,566.00 7,123.00 8,882.00 9,255.00 1st Year $ $ $ $ $ $ 1,475.00 1,590.00 1,636.00 1,774.00 2,213.00 2,305.00 2nd Year $ $ $ $ $ $ 2,630.00 2,835.00 2,917.00 3,164.00 3,945.00 4,111.00 Nurse Practitioner Rating Classes Class N1: Specializing in Dermatology, Geriatric, Women’s Health Care, Oncology, Gynecology, or Correctional Facility 10 hours/week 3rd Year $ $ $ $ $ $ 3,552.00 3,829.00 3,939.00 4,273.00 5,328.00 5,552.00 4th Year $ $ $ $ $ $ 3,872.00 4,174.00 4,294.00 4,658.00 5,808.00 6,052.00 5th Year $ $ $ $ $ $ 4,566.00 4,922.00 5,064.00 5,493.00 6,849.00 7,137.00 NURSE PRACTITIONERS FLORIDA ANNUAL RATE TABLES CLAIMS MADE COVERAGE PART TIME PRACTICE RATES (10 HOURS OR LESS PER WEEK) CLASS N1 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N2 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N3 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N4 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 1st Year $ $ $ $ $ $ 426.00 459.00 473.00 513.00 639.00 666.00 1st Year $ $ $ $ $ $ 603.00 650.00 668.00 725.00 904.00 942.00 1st Year SELF EMPLOYED 2nd Year 3rd Year $ 760.00 $ $ 819.00 $ $ 843.00 $ $ 914.00 $ $ 1,140.00 $ $ 1,187.00 $ $ $ $ $ $ $ 956.00 1,031.00 1,060.00 1,150.00 1,434.00 1,494.00 $ $ $ $ $ $ SELF EMPLOYED 2nd Year 3rd Year $ $ $ $ $ $ 1,075.00 1,159.00 1,192.00 1,293.00 1,613.00 1,680.00 $ $ $ $ $ $ 1,452.00 1,565.00 1,610.00 1,746.00 2,178.00 2,269.00 1,389.00 1,497.00 1,540.00 1,671.00 2,083.00 2,170.00 $ $ $ $ $ $ 1,876.00 2,023.00 2,081.00 2,257.00 2,814.00 2,932.00 1,705.00 1,838.00 1,891.00 2,051.00 2,558.00 2,665.00 $ $ $ $ $ $ 2,304.00 2,483.00 2,555.00 2,771.00 3,456.00 3,601.00 $ $ $ $ $ $ 1,319.00 1,422.00 1,463.00 1,587.00 1,979.00 2,062.00 1st Year $ $ $ $ $ $ 329.00 355.00 365.00 396.00 494.00 514.00 2nd Year $ $ $ $ $ $ 587.00 632.00 651.00 706.00 880.00 917.00 3rd Year 4th Year 5th Year $ 793.00 $ 864.00 $ 1,019.00 $ 855.00 $ 931.00 $ 1,098.00 $ 879.00 $ 958.00 $ 1,130.00 $ 954.00 $ 1,039.00 $ 1,226.00 $ 1,189.00 $ 1,296.00 $ 1,528.00 $ 1,239.00 $ 1,350.00 $ 1,592.00 EMPLOYED $ $ $ $ $ $ 1,583.00 1,706.00 1,755.00 1,904.00 2,374.00 2,474.00 5th Year $ $ $ $ $ $ 1,866.00 2,012.00 2,070.00 2,245.00 2,799.00 2,917.00 1st Year $ $ $ $ $ $ 466.00 502.00 516.00 560.00 699.00 728.00 2nd Year 3rd Year $ 830.00 $ $ 894.00 $ $ 920.00 $ $ 998.00 $ $ 1,245.00 $ $ 1,297.00 $ 1,121.00 1,208.00 1,243.00 1,348.00 1,681.00 1,752.00 4th Year $ $ $ $ $ $ 1,222.00 1,317.00 1,355.00 1,470.00 1,833.00 1,909.00 5th Year $ $ $ $ $ $ 1,441.00 1,553.00 1,598.00 1,733.00 2,161.00 2,252.00 EMPLOYED 4th Year $ $ $ $ $ $ SELF EMPLOYED 2nd Year 3rd Year $ $ $ $ $ $ 1,119.00 1,206.00 1,241.00 1,346.00 1,678.00 1,748.00 5th Year 4th Year SELF EMPLOYED 2nd Year 3rd Year $ 779.00 $ $ 840.00 $ $ 864.00 $ $ 937.00 $ $ 1,169.00 $ $ 1,218.00 $ 1st Year 1,026.00 1,106.00 1,138.00 1,235.00 1,539.00 1,604.00 EMPLOYED 4th Year 2,045.00 2,204.00 2,268.00 2,460.00 3,067.00 3,196.00 5th Year $ $ $ $ $ $ 2,411.00 2,599.00 2,674.00 2,901.00 3,617.00 3,769.00 1st Year $ $ $ $ $ $ 601.00 648.00 667.00 723.00 902.00 940.00 2nd Year $ $ $ $ $ $ 1,072.00 1,156.00 1,189.00 1,290.00 1,608.00 1,676.00 3rd Year $ $ $ $ $ $ 1,448.00 1,561.00 1,606.00 1,742.00 2,172.00 2,263.00 4th Year $ $ $ $ $ $ 1,578.00 1,701.00 1,750.00 1,899.00 2,367.00 2,467.00 5th Year $ $ $ $ $ $ 1,861.00 2,006.00 2,064.00 2,239.00 2,792.00 2,909.00 EMPLOYED 4th Year $ $ $ $ $ $ 2,511.00 2,707.00 2,784.00 3,020.00 3,766.00 3,924.00 5th Year $ $ $ $ $ $ 2,961.00 3,192.00 3,283.00 3,562.00 4,441.00 4,628.00 1st Year 2nd Year $ 738.00 $ $ 795.00 $ $ 818.00 $ $ 887.00 $ $ 1,107.00 $ $ 1,153.00 $ 1,315.00 1,418.00 1,459.00 1,582.00 1,973.00 2,056.00 Nurse Practitioner Rating Classes Class N1: Specializing in Dermatology, Geriatric, Women’s Health Care, Oncology, Gynecology, or Correctional Facility 10 hours/week 3rd Year $ $ $ $ $ $ 1,776.00 1,915.00 1,970.00 2,137.00 2,664.00 2,776.00 4th Year $ $ $ $ $ $ 1,936.00 2,087.00 2,147.00 2,329.00 2,904.00 3,026.00 5th Year $ $ $ $ $ $ 2,283.00 2,461.00 2,532.00 2,747.00 3,425.00 3,569.00 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 1 NPSecure® Malpractice Insurance For Nurse Practitioners 1) Please print a copy of this application to your desktop printer. 2) Complete this hard copy by hand, answering all questions 3) Sign, date and either: a. Mail your completed application providing your credit card information OR with check payable to: CM&F Group, Inc., 99 Hudson Street, 12th Floor, New York, NY 10013 OR b. Fax your signed and completed application providing your credit card information (per the application) to CM&F Group, Inc. at (646) 390.5163 4) Once your application is processed & approved, your policy will be mailed within 5-7 business days. Your payment — whether by check or credit card — will NOT be processed until your coverage has been approved. MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 2 If previously covered with Medical Protective, please enter Fax or Mail Completed Application To: CM&F Group, Inc. the policy number ________________________________ 99 Hudson Street, 12th Floor New York, New York 10013-2815 (212)233-8911 (800)221-4904 Fax (646)390.5163 [email protected] THe MedICal ProTeCTIve CoMPaNY (a Stock Company) HealTHCare ProFeSSIoNal – ProFeSSIoNal lIabIlITY INSuraNCe aPPlICaTIoN – NP I. General Information Please print legibly. Please answer all questions; if a question is not applicable, state “N/a”. a. ____________________________________________________________________________________________________________________ First Name __________________ Degree (DNP/MA) Middle Initial ________ Suffix Last Name _____ / _____ / __________ ___________________________________ Date of Birth MM/DD/YYYY Professional License Number _________________ Graduation Year ____________________________________________________________ ____________________________ ______________________ Street Address Apartment/Suite # City ________________________ County ______-_____-_______ Business Phone ______ State _____________ Zip Code ______-______-_______ Business Fax _____________________ State of Practice _______________________________________ National Provider Identifier # (Optional) _______-______-________ Residence/Cell Phone E-mail Address: ____________________________________________________________________________ b. requested effective date: _____ /_____ /______ MM DD YYYY II. Coverage Information *Please note that requested policy types may not be available in all states. a. Coverage desired: ___ Occurrence coverage ___ Claims-Made coverage without Prior Acts coverage PleaSe Call For More INForMaTIoN ___ Claims-Made coverage with Prior Acts coverage PleaSe Call For More INForMaTIoN ___ Convertible Claims-Made coverage PleaSe Call For More INForMaTIoN b. retroactive date shown on my current Claims-Made policy is: (This date is not a requirement for Occurrence or Claims-Made without Prior acts policies.) ____ / _____ / ______ MM DD YYYY C. If “occurrence” or “Claims-Made coverage without Prior acts coverage” was selected as the desired coverage and the most recent prior coverage was issued on a Claims-Made basis, please complete one of the following: __ An extended reporting endorsement (tail coverage) has been purchased. __ An extended reporting endorsement has not and will not be purchased. * Please be advised that if you do not purchase tail coverage (an extended reporting endorsement) from your current insurer where you are insured under a Claims-Made policy, this will result in an uninsured exposure for any claims which may arise as a result of professional services rendered or which should have been rendered while insured by your current insurer’s NP-APP-001-00 PAGE 1 OF 8 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 3 policy. If you do not purchase tail coverage from your current insurer, understand that the policy for which you are applying with The Medical Protective Company, if offered, will not provide prior acts coverage. Claims-Made coverage is limited generally to liability for injuries for which claims are first made during the policy period, for services rendered between the retroactive date and expiration date of the policy. Please contact your agent should you have any questions pertaining to the differences between Claims-Made and occurrence coverage. d. desired limits: * Please note that requested limits options may not be available in your state. __ $100,000/$300,000 __ $200,000/$600,000 __ $250,000/$750,00 __$500,000/$1,000,000 __ $1,000,000/$3,000,000 __ $1,000,000/$6,000,00 __$2,000,000/$6,000,000 __ va only: The limits of insurance for Insureds practicing in Virginia will equal the annual damages cap, as set out in VA Code Ann.§ 8.01-581.15 as amended, based upon the expiration date of the policy to which this application may become attached. e. are you an Indiana resident electing to participate in the Indiana Patient Compensation Fund? If yes, coverage provided will have limits of $250,000/$750,000. __ Yes __ No F. are you a louisiana resident electing to participate in the louisiana Patient Compensation Fund? If yes, coverage provided will have limits of $100,000/$300,000. __ Yes __ No G. If in Maryland, do you want to purchase administrative hearing coverage? __ Yes __ No Administrative Hearing Expense Coverage Option: $25,000 each limit/$100,000 aggregate limit. Defense arising out of Disciplinary, Licensure or similar Administrative Proceedings, arising from your professional services as a Healthcare Professional to a patient may be purchased for an additional premium. III. Practice Information a. Please indicate your Nurse Practitioner rating Class: (Please select all that are applicable. at least one must be selected.) N1: Dermatology Geriatric Women’s Health Care Oncology Gynecology Correctional Facility 10 Hours / Week NS: Students currently attending an accredited Nurse Practitioner Program * I understand that if I am a Nurse Anesthetist or Certified Nurse Midwife, I am not covered by this policy. b. If your specialty is ob/GYN, are you responsible for the labor or delivery of a fetus? __ Yes __ No __ N/A C. do you perform any major invasive surgical procedures? __ Yes __ No If yes, please give a general description: ______________________________________________________________________________ d. as a Nurse Practitioner I practice as: ___ Employee (W2 & not owner) ___ Self-Employed (File 1099 Tax Form) e. Indicate the estimated average number of hours you practice per week. _______________ F. Is your professional designation/certification currently valid? __ Yes __ No Please provide date of most recent certification: ___ / ___ / _____ MM G. Highest level of education: NP-APP-001-00 __ Masters (MS) DD YYYY __ doctorate (dNP) PAGE 2 OF 8 __ licensed Nurse Midwife 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 4 H. Have you completed training/education courses in addition to the level required for licensing/certification? If yes, please provide details. _________________________________________________________________________________________ I. If you are a student, what is the anticipated date of graduation? ___ /___ /______ MM J. are you a member of a Professional association(s)? DD YYYY __ Yes __ No If yes, please list membership affiliation(s) ____________________________________________________________________________ K. Have you completed a risk management education course within the last (12) months? __ Yes __ No Iv. additional Practice Information a. Have you ever been indicted for, charged with, or convicted of, any act committed in violation of any law or ordinance other than traffic offenses? __ Yes __ No If yes, please attach a separate sheet with full particulars including date(s). b. Have you ever had your hospital privileges, dea license, healthcare license or reimbursement privileges, refused, denied, revoked, suspended, restricted, subject to a reprimand, placed on probation or voluntarily surrendered? __ Yes __ No If yes, please attach a separate sheet with full particulars including date(s). C. Has any professional liability insurance company ever declined, refused, canceled or non-renewed your coverage? NoTe: MISSourI aNd CalIForNIa reSIdeNTS do NoT reSPoNd. __ Yes __ No If yes, please indicate the date(s) and explain: Date ____ /_____ _______________________________________________________ MM YYYY d. Have you ever been accused of sexual misconduct of any kind? If yes, please indicate the date(s) and explain: Date ___ /_____ MM __ Yes __ No ______________________________________________________ YYYY e. Have you ever incurred or become aware of having a condition that impairs your ability to practice your medical specialty? (i.e. convulsive disorders, mental illness, multiple sclerosis, addiction to alcohol, narcotics or other controlled substances, etc). __ Yes __ No * If yes, please complete Medical Condition Supplement v. loss Information Please complete the loss Information Supplement for each written request, incident, claim or suit that has NoT been covered by a Medical Protective policy. Report professional liability and malpractice-related matters, including but not limited 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 you even if you believe the claim or suit would be without merit. a. are you now, or have you ever been, involved in a claim, or suit, received a written request for treatment records arising out of the rendering or failure to render professional services, or related to any other coverage you are requesting from Medical Protective (e.g. CGL, EPLI, etc.)? __ Yes __ No If yes, how many? ______ b. are you aware of any complication, incident or adverse outcome resulting in injury or death that might reasonably result in a claim or suit against you? __ Yes __ No This includes, but it is not limited to, the following: ◊ amputation ◊ Permanent Neurological Injury ◊ loss of Major organ Function ◊ death ◊ loss of vision. If yes, how many? _______ C. In the last 12 months, have you received a written request from an attorney for treatment records concerning any current or former patient(s) which might reasonably result in a claim or suit against you? __ Yes __ No If yes, how many? _______ NP-APP-001-00 PAGE 3 OF 8 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 5 vI. Professional liability Coverage a. Please list your prior professional liability insurance, if any. Coverage Type Insurance Carrier (Occurrence or Claims-Made) Policy Number Limits Effective Date(s) Retro Date __________________ _________________________ _____________________ ___________ _______________ _____________ vII. Important Notice – representations, authorizations, releases and Notices MaNdaTorY: ALL APPLICANTS must read the following unless in a state listed below: 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, which may include voiding of the policy if allowed by state law. ALL ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. ALL ARKANSAS APPLICANTS: 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. ALL COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulated Agencies. ALL DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. ALL FLORIDA APPLICANTS: Any person who knowingly, and with intent to injure, defraud, or deceive any insurance company, files a statement of a claim containing false, incomplete or misleading information is guilty of a felony of the third degree. ALL GEORGIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. ALL HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. ALL KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. ALL MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. NP-APP-001-00 PAGE 4 OF 8 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 6 ALL MINNESOTA APPLICANTS: No oral or written misrepresentation made by the insured, or in the insured’s behalf, in the negotiation of insurance, shall be deemed material, or defeat or avoid the policy, or prevent its attaching, unless made with intent to deceive and defraud, or unless the matter misrepresented increases the risk of loss. ALL NEW HAMPSHIRE APPLICANTS: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud as provided in Section 638.20. ALL NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. ALL NEW MEXICO APPLICANTS: 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 civil fines and criminal penalties. ALL OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against and insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. ALL OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. ALL OREGON APPLICANTS: Any person who knowingly files an application for insurance or a statement of a claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, may have committed a fraudulent insurance act, which may be a crime and also punishable by criminal and/or civil penalties in certain jurisdictions. ALL PENNSYLVANIA 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. ALL RHODE ISLAND APPLICANTS: 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. ALL TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. ALL VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. ALL VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, or denial of insurance benefits. ALL WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, or denial of insurance benefits. ALL WEST VIRGINIA APPLICANTS: 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. NP-APP-001-00 PAGE 5 OF 8 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 7 vIII. Notes and agreements 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 s (hereinafter “s”) for the purposes of my initial or renewal application, are true and that I have not knowingly suppressed or misstated any material facts and I or any applicant agree that this application, and any s, shall be the bases of the contract with the Company. I agree to notify the Company if there are any future material changes in any answer to this application, or its s, including without limitation, any change in professional specialty, affiliation or working arrangement with any other healthcare provider, facility, firm or professional association. Where allowed by state law, I understand that any material misrepresentation or omission made by me on this application may act to render any contract of insurance null and without effect or provide the Company with the right to rescind it. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. If arizona: I understand that, to the extent permitted by law, the Company reserves the right to deny coverage for any claim submitted under this policy if I have made misrepresentations, omissions, or incorrect statements, or if I have concealed facts that are: (1) fraudulent; (2) material either to the acceptance of the risk or to the hazard assumed by the Company; and (3) the Company in good faith would either not have issued the policy, or would not have issued the policy in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the Company as required either by this application for the policy, subsequent notice, or otherwise. If delaware: Misrepresentations, omissions, concealment of facts and incorrect statements shall not prevent a recovery under the policy or contract unless either: (1) Fraudulent; or (2) Material either to the acceptance of the risk or to the hazard assumed by the insurer; or (3) The insurer in good faith would either not have issued the policy or contract, or would not have issued it at the same premium rate or would not have issued a policy or contract in as large an amount or would not have provided coverage with respect to the hazard resulting in the loss if the true facts had been made known to the insurer as required either by the application for the policy or contract or otherwise. If Georgia: I understand that any material misrepresentation or omission made by me on this application may provide the Company with the right to cancel the policy and/or deny coverage for any claim submitted under this policy if I have made misrepresentations, omissions, or incorrect statements, or if I have concealed facts that are: (1) fraudulent; (2) material either to the acceptance of the risk or to the hazard assumed by the Company; and (3) the Company in good faith would either not have issued the policy, or would not have issued the policy in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the Company as required either by this application for the policy, subsequent notice, or otherwise. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. If Kansas: An insurer shall not be required to provide coverage or pay any claim involving a fraudulent insurance act. A fraudulent insurance act is committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto. If Maine: I understand that any material misrepresentation or omission made by me on this application may cause coverage to be cancelled and/or denied. However, we maintain the right to request a ruling from the Maine Courts on voidance or rescission of this policy. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. If New Hampshire: I understand that any material misrepresentation or omission made by me on this application may provide the Company with the right to cancel my policy pursuant to state law and pursue further legal action against me. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. NP-APP-001-00 PAGE 6 OF 8 02/12 MPro(NP-GNR)PrntAp (6.24F.14)_PA/Gen Ap (5/2/03) 6/26/14 12:37 PM Page 8 If oklahoma: I understand that any material misrepresentation or omission made by me on this application may act to render any contract of insurance null and without effect or provide the Company with the right to rescind it. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. If vermont: Where allowed by state law, I understand that any material misrepresentation or omission made by me or any other applicant on this application may act to render any contract of insurance null and void and without effect or provide the Company the right to cancel it. By making this application, I am not, nor is any other applicant relying upon any oral or written representation that coverage has or will be extended or that a policy of insurance will be issued. If Washington: I understand that any intentional concealment or material misrepresentation made by me, or someone acting on my behalf, on this application may act to render any contract of insurance null and without effect. By making this application, I am not relying upon any oral or written representation that coverage has or will be extended to me or that a policy of insurance will be issued. I further understand and agree that I have no right to demand or expect coverage until the company has: (1) received my completed application; (2) my application has been accepted by the Company; and (3) received, as a preconditio…

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