Cna Form G 119639 A PDF Details

Medical practitioners seeking claims-made coverage for their professional liability can navigate this complex area through the CNA HealthPro Medical Practitioners Application, known as form CNA G 119639 A. This document serves as a comprehensive tool for individuals in the medical field to provide detailed personal and professional data, including basic identification, practice addresses, and contact information. It not only asks for the current policy information but also dives deeper into the medical training, history, potential legal challenges, and the specific nature of the practitioner's medical practice. The form requires meticulous records of medical education, board certifications, memberships in professional associations, and any past incidences that might affect the ability to practice medicine, such as legal or disciplinary action, to assess risk and determine the terms of coverage accurately. Moreover, it includes a thorough exploration of the applicant's insurance history, current medical practices, and the extent of their surgical and non-surgical roles, emphasizing the importance of detailed disclosure to facilitate a fair evaluation and issuance of the appropriate policy limits and terms. This form acts as a bridge between medical practitioners and the insurer (CNA), ensuring that coverage reflects the practitioner's current professional standing and practice specifics, thereby offering a customized insurance solution that meets their unique needs.

QuestionAnswer
Form NameCna Form G 119639 A
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesHealtPhysAppPhy siciansNBIdaho_ CNA cna healthpro medical practitioners renewal application form

Form Preview Example

CNA HEALTHPRO

MEDICAL PRACTITIONERS APPLICATION

CLAIMS-MADE COVERAGE

I PERSONAL/PROFESSIONAL DATA

Name (last, first, middle, designator)

Clinic name/Employer

Date of birth (MM/DD/YY)

Primary practice address

City

State

 

Zip Code

County

 

 

 

 

 

 

 

 

 

 

 

 

Residence address

City

State

 

Zip Code

County

 

 

 

 

 

 

 

 

 

 

 

Telephone - office

Fax number

 

 

Telephone – residence

 

 

 

 

Number of years at current office location

If less than three years, list previous locations and dates

 

 

 

 

Tax I.D. number

 

 

Social Security number

 

 

 

 

 

 

Additional practice locations

 

 

 

 

 

PLEASE ATTACH A COPY OF YOUR CURRENT POLICY DECLARATIONS PAGE AND BUSINESS LETTERHEAD. Desired policy dates

Effective date:

 

 

 

Prior Acts date:

 

 

 

Desired coverages/limits

 

 

 

Professional liability

$

each claim/ $

aggregate

Personal umbrella (not available in all states)

 

 

COMPANY/AGENCY USE ONLY

Territory

Dec ISO

PLD code

Policy number

Group

Producer number

Step

Rate ISO

Rate class

Account number

Producer’s name

G-119639-A

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II MEDICAL TRAINING AND HISTORY

Please answer all questions completely. If a question does not apply to you, mark “N/A” or “0.”

Do not leave any questions unanswered. If space is inadequate, use the Comments section or attach a separate sheet.

1.

Medical specialty:

 

 

 

Percentage of practice:

 

 

%

 

Sub-specialty:

 

 

 

Percentage of practice:

 

 

%

2.

Medical education

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Medical school: Institution

 

State

From

To

Completed?

 

 

 

 

 

 

 

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Internship: Institution

 

State

From

To

Completed?

 

 

 

 

 

 

 

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Residency: Institution

Specialty

State

From

To

Completed?

 

 

 

 

 

 

 

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. Residency: Institution

Specialty

State

From

To

Completed?

 

 

 

 

 

 

 

No

Yes

 

 

 

 

 

 

 

 

E. Fellowship: Institution

Specialty

State

From

To

Completed?

No

Yes

3.If you are a graduate of a foreign medical school:

are you certified by the Education Council for Foreign Medical Graduates?

have you passed the FLEX? No Yes

4.Number of hours continuing education completed within the past two years:

5.Date and location you began practicing:

Date

6.Medical license information

No Yes

hrs.

City,State

State

License number

Expiration date

Status

7.

Narcotics/DEA license number:

 

Status:

8.Board certification information

Name of board:

Name of board:

Name of board:

Certified

Certified

Certified

Qualified

Qualified

Qualified

G-119639-A

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II MEDICAL TRAINING AND HISTORY (continued)

9.List the corresponding medical associations/societies of which you are a member:

A.County:

B.State:

C.National:

10.Has your board certification or membership in any medical association/society ever been voluntarily or involuntarily suspended, denied, revoked or restricted in any state?

No

Yes — Explain:

11.Has your medical or narcotics license ever been voluntarily or involuntarily suspended, denied, revoked or restricted in any location?

No

Yes — Explain:

12.Have you ever been diagnosed with, or treated for, alcoholism, drug addiction, or mental or physical impairment?

No

Yes — Explain:

13.Have any fee, professional relations or other complaints been registered against you with any medical association, state licensing authority or hospital?

No

Yes — Explain:

14.Have you ever been charged with any criminal activity?

No

Yes — Explain:

15.Has any claim or suit for alleged sexual misconduct ever been brought against you?

No

Yes — Explain:

16.Have Medicare or Medicaid authorities ever brought charges against you?

No

Yes — Explain:

III INSURANCE HISTORY

1.

Carrier information

 

 

 

 

 

Current carrier

First prior carrier

Second prior carrier

 

 

 

 

 

 

Insurance company

 

 

 

 

 

 

 

 

 

Coverage form

Claims-made

Claims-made

Claims-made

 

Occurrence

Occurrence

Occurrence

 

 

 

 

 

 

 

 

Policy period

 

 

 

 

 

 

 

 

 

Limit of liability

 

 

 

 

per claim/aggregate

 

 

 

 

 

 

 

 

 

 

Deductible

Deductible

Deductible

 

Deductible or S.I.R. and amount

S.I.R.

S.I.R.

S.I.R.

 

 

$

$

$

 

 

 

 

 

 

Prior Acts date

 

 

 

 

 

 

 

 

G-119639-A

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III INSURANCE HISTORY (continued)

2.Has your insurance for medical malpractice ever been canceled, suspended, non-renewed or declined?

No

Yes Explain:

3.Have you ever had professional liability insurance provided by CNA?

4.If you are currently insured by a claims-made policy:

A.Are you obtaining Extended Reporting (“tail”) coverage from your current insurance company?

B.Is Prior Acts coverage being requested? If Yes, show Prior Acts effective date:

and attach a copy of your most recent policy declarations page.

C.Has your practice changed significantly in the last five years?

No Yes Explain:

No

No No

Yes

Yes Yes

Note: To prevent possible gaps in your claims-made coverage, either Extended Reporting or Prior Acts coverage must be purchased.

IV CURRENT MEDICAL PRACTICE

1.Do you practice medicine on a part-time (20 hours or less per week) basis?

2.

Percentage of your practice outside of your primary state?

%

 

 

 

List States:

 

 

 

 

 

 

3.

Percentage of your practice devoted to practicing as a locum tenens:

%

4.

Type of practice: (Check all that apply.)

 

 

 

 

 

Solo Practitioner

 

 

 

 

 

 

Partnership

Name:

 

 

 

 

 

Group

Name:

 

 

 

 

 

Employee

Of:

 

 

 

 

 

Space sharing

With:

 

 

 

 

 

Independent contractor

For:

 

 

 

 

No

Yes

5.Do you supervise residents?

No

Yes

If yes, how many?

6.Do you have any medically related duties that are insured by another company or for which you do not desire CNA Coverage?

No

Yes Explain:

 

 

 

Percentage of

 

 

7.

Check all with which you are associated:

Name

Practice

Relationship

 

Solo Practitioner

 

 

 

 

 

Governmental body

 

 

 

 

 

Military service

 

 

 

 

 

Educational institution

 

 

 

 

 

 

 

 

 

 

Professional sports team

 

 

 

 

 

Clinic with inpatient facilities

 

 

 

 

 

 

 

 

 

 

Urgent care center

 

 

 

 

 

Commercial laboratory

 

 

 

 

 

Administrative position

 

 

 

 

 

Surgicenter

 

 

 

 

 

Office with surgical suite

 

 

 

 

 

Nursing home or long term care facility

 

 

 

 

 

 

 

 

 

 

G-119639-A

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IV CURRENT MEDICAL PRACTICE (continued)

8.Are you under contract (other than PPO, HMO, IPA or anything listed in Question 7) in any capacity involving the practice of medicine?

No

Yes Explain:

9.

Do you have hospital privileges?

No*

Yes

 

 

 

Hospital Name

 

 

City, County, State

Type of privilege

 

 

 

 

 

Full

Courtesy

 

 

 

 

 

Restricted

Other*

 

 

 

 

 

 

 

 

 

 

 

 

Full

Courtesy

 

 

 

 

 

Restricted

Other*

 

 

 

 

 

 

 

 

 

 

 

 

Full

Courtesy

 

 

 

 

 

Restricted

Other*

 

 

 

 

 

 

 

*If No, Restricted or Other, please explain on your letterhead.

10.Have your hospital privileges ever been suspended, denied, revoked, restricted or otherwise sanctioned?

No Yes Explain:

11.Do you work in the emergency department other than to fulfill requirements for you hospital privileges?

No Yes List number of hours per week:

12.Do you perform or assist in any surgical procedure in a non-hospital setting during which general anesthesia is administered?

No Yes Complete the following:

A.Do you follow ASA standards for preoperative monitoring?

No

Yes

B.

Number of procedures annually:

 

Description:

C.Anesthesia administered by:

13.Do you perform surgery (see categories - these lists may not be all inclusive)?

No Surgery — perform neither surgery nor obstetrical procedures. Incising of boils and superficial fascia, suturing or minor lacerations, removal of superficial skin lesions by other than surgical excision and assisting in surgery are not considered surgery.

No

Yes

Minor Surgery — applies to all general practitioners or specialists, except those performing major surgery or anesthesiology, who may perform any of the following medical techniques or procedures: colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP), pneumatic or mechanical esophageal dilation (not with bougie or olive), tonsillectomies, and adenoidectomies.

No

Yes

Please list types of procedures routinely performed:

Major Surgery — includes operations in or upon any body cavity including, but not limited to, the carnium, throax, abdomen, pelvis or any other operation which because of the condition of the patient or length of the circumstances of the operation presents a distance hazard to life. It also includes: removal of tumors, open bone fractures, amputations, termination of pregnancy, the removal of any gland or organ (excluding tonsillectomies and adenoidectomies), plastic surgery and any operation done using general anesthesia.

No Yes

number per year

Please list types of procedures routinely performed:

G-119639-A

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IV CURRENT MEDICAL PRACTICE (continued)

14.Please answer the following. If you answer yes to any question with asterisks(**), please explain fully on your letterhead.

Average number of patients seen per week:

Do you perform the following procedures?

A.Elective cosmetic surgery

B.Itinerant surgery

C.Vaginal deliveries

D.Cesarean sections

E.Deliveries outside the hospital

F.Abortions

G.Neonatology

H.Professional sports medicine

I.Angiography/arteriography/ cardiac catheterization

No

No

No

No

No

No

No

No

No

Yes — percentage of practice:

 

%

Yes **

Yes — number per year:

Yes — number per year:

Yes **

Yes

percentage of practice:

 

%

Yes

percentage of practice:

%

Yes **

 

 

 

Yes

 

 

 

 

J.Experimental procedures

K.Weight control surgery/drugs

No

No

Yes **

Yes ** percentage of practice:

 

%

L.If you are a primary care physician, do you automatically receive the results of tests and consultation/exam reports ordered by the physician/surgeon to whom your patient was referred?

No

Yes — How quickly do receive them?

V CLAIMS HISTORY

Has any claim or suit for alleged malpractice ever been brought against you or are you aware of any circumstances that might lead to such a claim or suit?

No

Yes — Complete the following. If you need more space, use the comments section or attach an additional sheet.

Patient’s name

Insurance carrier

Allegations

Claim closed.

Claim open.

Date of occurrence

Location of occurrence

Amount paid on your behalf

$

Amount reserved on your behalf

$

G-119639-A

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V CLAIMS HISTORY (continued)

Patient’s name

Insurance carrier

Allegations

Claim closed.

Claim open.

Patient’s name

Insurance carrier

Allegations

Claim closed.

Claim open.

Patient’s name

Insurance carrier

Allegations

Claim closed.

Claim open.

Date of occurrence

Location of occurrence

Amount paid on your behalf

$

Amount reserved on your behalf

$

Date of occurrence

Location of occurrence

Amount paid on your behalf

$

Amount reserved on your behalf

$

Date of occurrence

Location of occurrence

Amount paid on your behalf

$

Amount reserved on your behalf

$

G-119639-A

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COMMENTS SECTION

Question number Comments

AUTHORIZATION

I have answered the questions in the Application to the best of my ability and declare that, to the best of my knowledge, the statements set forth herein are true and correct. My signing of the Application does not bind the Insurance Company to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a policy be issued.

For FL, KY, MN, NJ, NY, OH and PA residents only: Any person who knowingly and with intent to defraud any Insurance Company or other person who 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. For NY residents only: And shall also be subject to a civil penalty not to exceed five thousand ($5,000) dollars and the stated value of the claim for each such violation.

Signature in Full

Date

Name - Please print

ALL QUESTIONS MUST BE ANSWERED AND THE APPLICATION MUST BE SIGNED AND DATED.

This program is underwritten by and Application is made to one of the CNA Insurance Companies. CNA is a registered service mark of the CNA Financial Corporation.

G-119639-A

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