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Information To Accompany The
Application |
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To help us expedite your quotation,
please include copies of the material listed below when submitting the
completed Application. If any of the requested items are
unavailable or not applicable to the Applicant then please so indicate
in the Remarks section. If the Applicant is requesting quotations
for both Directors and Officers and Professional Liability then the
material in both Section A and Section B should be included. |
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Section A - For a quotation for Professional Liability only: |
- Income/Expense Statement and Balance Sheet for the Applicant's most
recent fiscal year. Underwriters prefer financial statements,
review or compilation prepared by a CPA; however, internally generated
statements are acceptable. If the Applicant is in formation or has
been organized in the past 12 months, then please provide pro forma
financial statements. If pro forma statements are unavailable
please provide a copy of a detailed income/expense budget for the
Applicant's first two years of operation.
- Interim financial statements prepared subsequent to the last year's
end reports.
- A Business Plan (if Applicant is newly formed or is in formation).
- A copy of the Applicant's standard contract(s) with providers
- The Applicant's guidelines/protocol for: Credentialing and
Peer Review; Utilization Review and Quality Assurance; and Enrollee
grievances relative to benefit denial.
- Samples of all brochures and other promotional/sales materials which
bear the identity of the Applicant.
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Section B - For a quotation for Directors and Officers Liability only: |
- Financial Statements as listed in items 1 and 2 above are
mandatory.
- A copy of the indemnification Provision for directors and
officers from the Applicant's Bylaws.
- A list of the Applicant's directors and officers and their
respective outside affiliations.
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IF A POLICY IS ISSUED, IT WILL BE ON
A CLAIMS-MADE BASIS
NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO
PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR
LEGAL DEFENSE, FURTHER NOTE THAT AMOUNTS INCURRED FOR LEGAL DEFENSE
SHALL BE APPLIED TOWARDS THE SATISFACTION OF THE DEDUCTIBLE. |
