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Employee and Officer LIABILITY INSURANCE APPLICATION

Application Notes

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Application (PDF) files
General Information
Name of Applicant
Address
City
State
Zip Code
Phone Number
Are you working with someone from Million Insurance?
If Yes, please provide their name
Limit Of Liability for Directors & Officers plus Professional Liability (combined policy)
Limit Of Liability for Professional Liability only
Limit Of Liability for Directors & Officers only
Name and title of the Officer designated by the Applicant to receive any and all notices from the Insurer on behalf of all personal and entities proposed for this insurance.

Please include Name, Title and Telephone
The Applicant Is:
If the Applicant is a non-profit entity, are there any plans to convert to a for-profit status in the next 12 months?
Type of Organization
Gross Revenue
Last 12 Months Next 12 Months
Is the Applicant owned, managed or controlled by any other entity?

If so, please give full details in the Remarks section
Is the Applicant involved in any joint ventures?
List all subsidiaries of which 50% or more of its Common Stock is owned or controlled by the Applicant or for which the Applicant has the right to appoint 50% or more of the directors or persons serving in an equivalent capacity - continue in remarks if more space is required.
Name Type of Operation % of Ownership Date Acquired
Is coverage to include all subsidiaries?
Does the Applicant contract directly with any employers, union trusts or employer groups?
Does the Applicant assume capitated or percentage of premium risk on behalf of itself or any of its contracted providers?
If no, is the assumption of such risk contemplated within the next 12 months?
List all payor organizations with which the Applicant contracts and check the appropriate box which best describes the type of payor organization
Name Of Payor HMO Indemnity Insurer Approx No. of Covered Lives
List all payor organizations with which the Applicant contracts and check the appropriate box which best describes the type of payor organization
Name Of Payor Self Funded Employer TPA Approx No. of Covered Lives
Does any payor organization with which the Applicant contracts require the Applicant to maintain Professional Liability insurance?
Total number of encounter by panel providers with patients introduced by or through the Applicant:
Last 12 Months Next 12 Months
Does the Applicant belong to and comply with the standards of any certification/accreditation agency or association?
If yes, please give name or names of such agency/association
Has the Applicant's certification/accreditation ever been revoked or suspended?
Is certification/accreditation subject to any contingencies or recommendations?
To what trade groups and/or associations do you belong?
Has the Applicant ever been cited for any violation of Federal, State or local licensing requirements for operations?
If yes, please explain corrective action taken
Does the Applicant own or manage a hospital, inpatient or outpatient clinic, pharmacy or other medical facility?
If yes, please provide details
Does the Applicant give or require Hold Harmless Agreements to/with contracted providers?
If yes, please provide details
Name of Firm acting as legal counsel to the Applicant
Does the Applicant employ physicians, psychologists, dentists, or any other health care professional in any medical capacity, other than in peer review, utilization or administrative duties?
If yes, please provide details
Has the Applicant retained the services of any industry consultants for advice on the design or implementation of administrative, contractual or marketing arrangements or procedures?
If yes, please provide name and address of such consultant
Professional/E&O
Insurance Carrier Policy Period Limits Deductible Premium
Directors & Officers
Insurance Carrier Policy Period Limits Deductible Premium
Stop Loss
Insurance Carrier Policy Period Limits Deductible Premium
Has any Insurance carrier, Reinsurance carrier canceled or non-renewed any of the above coverages?
If yes, please explain
Does the Applicant provide services to or contract with any governmental/municipal, school, religious groups or benefit plans?
 Profile Of Provider Network
Number of Physicians under contract - not including Psychiatrists
Last 12 Months Next 12 Months
Number of Psychiatrists under contract
Number of Psychologists under contract
Number of Other Practitioners under contract
Number of Hospitals under contract
Number of Other Institutions under contract - e.g. clinics
Excluding General and Internal medicine, identifty any medical specialty in which more than 25% of your contracted providers specialize:
Specialty % of Provider Network
Are all medical services provided under written contracts between the Applicant and health care providers?

If yes, attach a sample copy of such contracts
Does the Applicant have any risk sharing, profit sharing or other financial inducement arrangements with any contracted health care providers or claims handling organization?

If yes, then provide a copy of the contractual agreement which addresses such arrangements or refer to the specific
Does the Applicant require its contracted providers to maintain Medical Malpractice insurance?
If yes, then what minimum limits are required?
If yes, briefly describe Applicant's procedure to ensure that such coverage is maintained and renewed by all contracted providers
Credentialing
Does the Applicant perform credentialing of health care providers

If yes, then please answer all questions in this section
Identify, by number, for which payor organizations as listed in Question 12 above, does the Applicant perform credentialing services.
Does the Applicant provide credentialing services to other for a fee?
If yes, please provide total fees charged:
Last 12 Months Next 12 Months
How often does the Applicant recredential members of its provider panel?
Does the Applicant inquire as to any mental or physical disorders which could impair a provider's ability to practice?
Does the Applicant directly or indirectly access any available provider data banks during the credentialing process?
If yes, please identify the data bank
Are insufficient patient encounters, excessive utilization or any other economic factors grounds to disqualify or remove a provider from the Applicant's panel?
Have any providers been disqualified or removed from the Applicant's provider panel in the past 12 months?
If yes, how many?
Have any providers, who applied, been denied membership to the panel?
If yes, how many applicants denied?
Does the Applicant maintain written protocols/guidelines for credentialing and recredentialing?

If yes, please provide copies of each
Section 4 - Utilization Review and Claims Handling
Does the Applicant conduct retrospective utilization review?
Does the Applicant conduct concurrent utilization review?
Does the Applicant conduct prospective utilization review?
Does the Applicant conduct case management?
Does the Applicant contract out utilization review work to any third party?
If yes, please identify such third parties
Does the Applicant contract out credentialing review work to any third party?
If yes, please identify such third parties
Does the Applicant require the third party to furnish evidence of Professional Liability Insurance?
If yes, how much coverage does the third party carry?
What deductibles are applicable
Does the Applicant provide utilization review services for a fee?
Gross Revenues?
Last 12 Months Next 12 Months
Number of cases reviewed?