Masm 5018 Form PDF Details

The MASM 5018 form is a comprehensive document that serves as an application for specified medical professions seeking professional liability insurance on a claims made basis. It outlines a series of instructions for the applicant, mandating detailed responses and the inclusion of supplemental information where necessary. This form requires the applicant to disclose a broad range of information covering basic identifying details, practice information including the type and location of the practice, professional education and experience, detailed descriptions of the services provided, and any affiliations or advertising practices. Moreover, it delves into specifics such as the types of procedures performed, the employee and patient interaction, and other operational facets like ownership of or association with other businesses, potential for advertising and soliciting patients, and handling of sensitive health information under HIPAA regulations. The form not only assesses eligibility for coverage but also works toward understanding the risks associated with the applicant’s practice. Further, it includes sections dedicated to the applicant's history and claims, requiring disclosures on past disciplinary actions, convictions, treatments for substance dependencies, previous insurance details, and any circumstances that could potentially lead to a malpractice claim. This meticulous approach ensures that the insurance provider can accurately gauge the liability and operational risks presented by the applicant, thereby aligning the coverage terms appropriately.

QuestionAnswer
Form NameMasm 5018 Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesmasm specified medical printable, masm 5018 professional, masm specified medical download, 5018 medical professions fill

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APPLICATION FOR SPECIFIED MEDICAL PROFESSIONS

FOR PROFESSIONAL LIABILITY INSURANCE

(Claims Made Basis)

APPLICANT’S INSTRUCTIONS:

1.Answer all questions. If the answer requires detail, please attach a separate sheet.

2.Application must be signed and dated by owner, partner or officer.

3.Please do not complete application earlier than 45 days before proposed effective date of coverage.

4.PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION.

(PLEASE TYPE OR PRINT IN INK)

1.APPLICANT INFORMATION

a.Full name of Applicant (include professional degree if applicant is an individual):

b.Principal business premise address:

 

(Street)

(County)

 

 

 

(City)

(State)

(Zip)

Please attach a list of additional office addresses.

c.Number of Employees: Full time _____ Part time _____ Seasonal _____ Total _____

d.

Business Phone: (

)

 

Home Phone: (

)

 

e.

Date of Birth:

 

 

 

 

Place of Birth:

 

 

 

 

 

Are you a U.S. citizen? [

] Yes [ ] No. If No, your status, date of entry into USA:

 

f.Square feet of total office space (all locations):

g.Your practice:

[ ] Solo practitioner (unincorporated) [ ] Solo practitioner (incorporated)

[ ] Partnership

[ ] Professional Association

[] Professional corporation (for profit)

[] Professional corporation (non-profit)

[] Employee of ___________________________________

(Give name of employer)

[ ] Other (please describe)______________________________________________________________________

h.Formal business, corporate or partnership name:

i.Please list the names of all partners or members of your professional association/corporation who provide professional services:

j.Please attach a copy of your letterhead.

k.Is the Applicant a “Covered Entity” under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Privacy Rule?

[

] Yes

[

] No

If yes,

 

 

 

 

(i)

Has the Applicant implemented procedures to comply with the HIPAA Privacy Rule?

[

] Yes

[

] No

(ii)

Provide the name and title of the Applicant’s Privacy Officer.

 

 

 

 

 

Our Business Associate Agreement is available at www.markelcorp.com. This is the only Business Associate Agreement we will recognize.

MASM 5018 (02/10)

Page 1 of 6

2.EDUCATION/EXPERIENCE (Individual Applicant Only)

Institution

 

 

Name and Address

Years of Training

Degree or Certification Attained

__________________________________

From ________ To ________

_________________________

__________________________________

From ________ To ________

_________________________

__________________________________

From ________ To ________

_________________________

(i)Where have you practiced your profession during the last ten years?

In

 

From

 

To

In

 

 

 

 

 

 

From

 

To

In

 

 

 

 

 

 

From

 

To

 

 

 

 

 

 

(ii) Have you ever failed any professional licensing or specialty organization examination?

[ ] Yes [ ] No

If yes, please attach a detailed explanation including the dates and location.

 

 

3.APPLICANT PRACTICE

a.Please list all the states where you are licensed to practice. If NONE, please attach an explanation.

b.Please indicate your professional specialty (CHECK ONE):

[

] Chiropractor

[

] Naprapath

[

] Pharmacist

[

] Counselor ( Describe)

[ ] Nurse, Licensed Practical

[

] Physical Therapist

_____________________

[

] Nurse, Registered

[

] Psychologist

[

] Dental Hygienist

[

] Nurses Registry

[

] Social Worker

[ ] Hearing Aid Fitter

[

] Occupational Therapist

[

] Speech Therapist

[ ] Home Health Care Agcy.

[

] Optician

[

] Veterinarian

[

] Inhalation Therapist

[

] Optometrist

[ ] Visiting Nurse Assoc.

[

] Laboratory Technician

[

] Orthotist

[

] X-ray Technician

[ ] Medical Personnel Pool

[

] Perfusionist

[

] Other (Specify)

 

c.Please indicate the sources and amounts of actual and projected revenue:

 

Source

Amount This Fiscal Year

Amount Next Fiscal Year

(i)

Charitable Contributions:

$__________________

$__________________

(ii)

Government Funding:

$__________________

$__________________

(iii)

Fee for Services:

$__________________

$__________________

(iv)

Other:__________________

$__________________

$__________________

TOTAL GROSS REVENUE

$__________________

$__________________

d.Please provide the number of patient or client visits:

 

Number of Visits

Number of Visits

Type of Visit

Last 12 Months

Next 12 Months

Clinic

_________________

_________________

Laboratory

_________________

_________________

Other (specify)________________

________________

_________________

TOTAL NUMBER OF VISITS

_________________

_________________

e.Please specify any professional societies or associations in which you are a member:

f.

Are you associated with or do you work for a physician or surgeon?

[ ] Yes [ ] No

 

If yes, please give the name and the specialty of the physician:

 

 

MASM 5018 (02/10)

Page 2 of 6

g.Please give the approximate percentage of time spent in the following work locations:

_____% Administrative Office

_____% Laboratory

_____% Hospital Ward (specify)

_____% Classroom

_____% Operating Room

 

_____% Emergency Dept of Hospital

_____% Outpatient Clinic

_____% Professional Office (specify profession)

_____% Nursing Home

_____% Patient’s Home

 

_____% Other (specify)

 

 

 

h.Please indicate the approximate division of your patients or clients among:

_____% Hemodialysis

_____% Psychiatric

_____% Bariatrics

_____% Holistic Medicine

_____% Drug Addicts

_____% Physical Rehabilitation

_____% Surgical

_____% Alcoholics

_____% Disability Evaluation

_____% Stress Testing

_____% Obstetrical

_____% Research or Experimental

_____% Communicable

_____% Dental

_____% _____________________

_____% Family Planning

_____% Pediatric

_____% _____________________

i.Please indicate the number and type of your employees and/or volunteers. IF NONE, STATE NONE.

 

Type of Profession

No.

Type of Profession

No.

 

Inhalation Therapists

__________

Opticians

__________

 

Laboratory Technicians

__________

Optometrists

__________

 

Nurse Anesthetists

__________

Perfusionists

__________

 

Nurses, Licensed Practical

__________

Pharmacists

__________

 

Nurse Practitioner

__________

Physiotherapists

__________

 

Nurses, Registered

__________

Social Workers

__________

 

Speech Therapists

__________

Other (please specify)

__________

j.

Are all of the above individuals licensed in accordance with applicable state and federal regulations?. [ ] Yes [ ] No

 

If no, please attach an explanation.

 

 

4.APPLICANT PROCEDURES

a.Do you render professional services directly to patients? [ ] Yes [ ] No. If yes, please describe in detail and indicate the extent of supervision by others.

 

 

 

 

Percent of

 

Qualifications

 

 

Description of Professional Services

Time Supervised

 

of Supervisor

 

___________________________________________________

__________ %

 

 

 

 

___________________________________________________

__________ %

 

 

 

 

___________________________________________________

__________ %

 

 

 

b.

 

Do you render professional services that do not involve contact with a patient? [ ] Yes [

] No. If yes, please describe

 

 

these services in detail.

 

 

 

 

 

 

 

 

 

 

 

c.

(i) Do you perform or assist in any surgical procedures? [ ] Yes [ ] No

 

 

 

(ii)Please list ALL surgical procedures performed (including minor surgery):

(iii)Is anesthesia (other than topical or by means of local infiltration) administered by either yourself or others?

 

[ ] Yes [

] No. If yes, please attach a detailed explanation.

 

 

 

 

 

 

(iv) Do you perform or assist in any surgical procedure(s) in a professional office or similar non-hospital facility?

 

[ ] Yes [

] No. If yes, please attach a detailed explanation.

 

 

 

 

 

d.

Do you perform radiation therapy?

[

] Yes

[

] No

e.

Do you perform psychiatric shock therapy?

[

] Yes

[

] No

f.

Do you compound in bulk, manufacture or wholesale medicine?

[

] Yes

[

] No

 

If yes, please provide a detailed explanation.

 

 

 

 

 

MASM 5018 (02/10)

 

Page 3 of 6

 

 

 

 

 

g.

(i) Do you perform veterinary services?

[

] Yes

[

] No

 

If yes, please indicate the approximate division of your work among the following categories.

 

 

 

 

_______ % Greyhounds

_______ % Thoroughbreds

 

 

 

 

_______ % Animals valued over $5,000.

 

 

 

 

 

Please attach an explanation including the frequency and the type(s) of animals treated.

 

 

 

h.

Do you administer artificial insemination?

[

] Yes

[

] No

 

If yes, please answer the following questions:

 

 

 

 

(i)What type(s) of animals are involved?

(ii) Are you responsible for the storage of the semen?

[ ] Yes [ ] No

If yes, please explain.

 

 

(iii)What percent of your practice is involved with artificial insemination? ________ %

i.Are you ever responsible for identifying contagious diseases in your locality and/or for

recommending remedial action?

[ ] Yes [ ] No

If yes, please attach a detailed explanation.

 

5.PERSONNEL

a.Please list the number and type of independent contractors who provide professional services on your behalf. IF NONE, STATE NONE.

 

No.

Type of Profession

No.

Type of Profession

No.

Type of Profession

 

_____

Inhalation Therapists

_____

Laboratory Technicians

_____

Nurse Anesthetists

 

_____

Nurses, Licensed Practical

_____

Nurse Practitioner

_____

Nurse, Registered

 

_____

Opticians

_____

Optometrists

_____

Perfusionists

 

_____

Pharmacists

_____

Physiotherapists

_____

Social Workers

 

_____

Speech Therapists

_____

Other (specify)_________________________________

b.

Do you supervise any individuals who are not your own employees? [ ] Yes [

] No. If yes, please provide a detailed

 

explanation of responsibilities and relationships to the entity which employs these individuals.

c.Please indicate by profession the number of individuals you supervise.

No.

Type of Profession

No.

Type of Profession

____

Physicians

____

Laboratory technicians

____

X-ray technicians

____

Other (please specify):___________________________

6.APPLICANT AFFILIATIONS

a.

Do you own or operate any business other than that shown in Question 1(a) above?

[

] Yes

[

] No

 

If yes, please give details on a separate sheet.

 

 

 

 

b.

Are you employed by any individual or entity other than that shown in Question 1(a) above?

[

] Yes

[

] No

 

If yes, please attach an explanation describing details of your responsibilities.

 

 

 

 

c.

Are you under contract to any individual or entity other than that shown in Question 1(a) above?

[

] Yes

[

] No

 

If yes, please attach an explanation describing details of your responsibilities. If your contract

 

 

 

 

 

contains a hold-harmless agreement, a copy of the contract must be attached.

 

 

 

 

d.

Are you employed by or under contract to any government entity?

[

] Yes

[

] No

 

If yes, please attach an explanation including the details of your responsibilities.

 

 

 

 

e.Do you advertise your professional services in any manner (other than a simple listing in a

telephone directory)?

[ ] Yes [ ] No

If yes, please attach a copy of ALL of your advertisements.

 

f.Are you associated with any agency or organization that engages in any kind of advertising for,

or solicitation of, patients?

[ ] Yes [ ] No

If yes, please attach a detailed explanation and a copy of ALL of your advertisements.

 

MASM 5018 (02/10)

Page 4 of 6

g.Do you own (wholly or in part), operate, or administer any hospital, nursing home or other

institutions where medical services are customarily rendered?

[ ] Yes [ ] No

If yes, please give details including the name, location, size and number of beds.

 

 

 

 

 

h.If you have a training school, please complete the following. Attach a separate sheet if needed.

Specify Profession

Max. No. Of

No. of

% of Time

 

 

For Which Students

Students

Sessions

Involved in

Number of

Qualifications of Faculty

Are Being Trained

Per Session

Per Year

Clinical Setting

Faculty

(e.g. MD, RN, PhD, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i.

(i)

Do you use a collection agency?

[

] Yes

[

] No

 

 

If yes, please state the name of the agency

 

 

 

 

 

(ii)

Does the agency have the authority to file a collection suit at its discretion?

[

] Yes

[

] No

7.APPLICANT HISTORY/CLAIMS

(Attach a detailed explanation for any YES answers) a. Have you or any of your employees:

(i)

Ever been the subject of disciplinary or investigative proceedings or reprimand by a

 

 

 

 

 

governmental or administrative agency, hospital or professional association?

[

] Yes

[

] No

(ii)

Ever been convicted for an act committed in violation of any law or ordinance other than

 

 

 

 

 

traffic offenses?

[

] Yes

[

] No

(iii)

Ever been treated for alcoholism or drug addiction?

[

] Yes

[

] No

(iv)

Ever had any state professional license or license to prescribe or dispense narcotics refused,

 

 

 

 

 

suspended, revoked, renewal refuses or accepted only on special terms or ever voluntarily

 

 

 

 

 

surrendered same?

[

] Yes

[

] No

(v)Ever had any insurance company or Lloyd’s cancel, decline, refuse to renew or accept only

on special terms their malpractice insurance?

[ ] Yes [ ] No

b.Please list prior professional liability insurance carried for each of the past four years. IF NONE, STATE NONE.

 

 

 

 

 

 

 

 

Was this a

 

 

Policy

Policy

Limits of

Deductible

 

Inception

Expiration

 

Claims Made

 

Insurance Carrier

Number

Liability

(If any)

Premium

Mo./Day/Yr.

Mo./Day/Yr.

 

Policy Form?

Retro Date

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

[

]

[

]

 

 

 

 

 

 

 

 

[

]

[

]

 

 

 

 

 

 

 

 

[

]

[

]

 

 

 

 

 

 

 

 

 

[

]

[

]

 

c.Does the Applicant currently participate in or plan to participate in a state patient compensation fund, health care stabilization fund or other governmentally established malpractice liability

 

funding mechanism?

[

] Yes

[

] No

d.

Has any claim or suit been brought against you and/or any of your employees?

[

] Yes

[

] No

 

If yes, a Supplemental Claim Information Form must be completed for each claim or suit.

 

 

 

 

e.Are you aware of any circumstances which may result in a malpractice claim or suit being made

or brought against you or any of your employees?

[ ] Yes [ ] No

If yes, please give details on a separate sheet.

 

MASM 5018 (02/10)

Page 5 of 6

*NOTICE TO APPLICANT: The coverage applied for is SOLELY AS STATED IN THE POLICY, which provides coverage on a "CLAIMS MADE" basis for ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD unless the extended reporting period option is exercised in accordance with the terms of the policy.

WARRANTY: I/We warrant to the Insurer, that I understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Insurer evidence its acceptance of this application by issuance of a policy. I/We authorize the release of claim information from any prior insurer to the underwriting manager, Company and/or affiliates thereof.

Name of Applicant

Title (Officer, partner, etc.)

 

 

 

Signature of Applicant

Date

SIGNING this application does not bind the Applicant or the Insurer or the Underwriting Manager to complete the insurance, but one copy of this application will be attached to the policy, if issued.

MASM 5018 (02/10)

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