Physical Therapist MPL

IMPORTANT! The rates shown in the matrix below are ONLY available for Applicants with the following characteristics:
- Generates no more than $500,000 in revenues annually
- No prior insurance claims in the last 5 years
- Requires no more than 3 years Prior Acts
- Not located in Kentucky
BY CHECKING THE BOX BELOW, APPLICANT WARRANTS THAT HE/SHE UNDERSTANDS THE RESTRICTIONS LISTED ABOVE. NO APPLICATION WILL BE CONSIDERED FOR COVERAGE UNDER THIS INITIATIVE UNLESS THIS WARRANTY HAS BEEN PROVIDED.*

I Understand
NOTE: APPLICANTS FALLING OUTSIDE OF THE PARAMETERS LISTED ABOVE MAY STILL BE ELIGIBLE FOR PROFESSIONAL LIABILITY INSURANCE THROUGH FOX POINT PROGRAMS. CONTACT US FOR DETAILS.
Please select your annual revenue range
- Bodily Injury and Property Damage (BI/PD) exposures are usually covered under a company’s General Liability policy. Many of these forms contain specific coverage exclusions for claims arising out of “professional services”. The intent of this restriction is to make sure losses resulting from a professional services incident are picked up by the appropriate Errors & Omissions policy.
  
  Unfortunately, most professional liability wordings follow the same logic – specifically excluding BI/PD losses that should be assumed by the firm’s General Liability. This creates a significant issue for the insured – having an exposure covered by neither policy.
  
  The Contingent BI/PD endorsement is designed to bridge this gap. It specifically provides coverage for BI/PD claims that arise from professional errors.
- 1. Contact Information
- Applicant Name:*
- dba Name:*
- Business Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number*
  Please enter a valid phone number.
- Fax Number
  Please enter a valid phone number.
- Email*
  example@example.com
- 2. What were the Applicant’s expected revenues over the last 12-month period?*
- 3. Is E&O Coverage currently in-force?*
  
  YesNo
- If “Yes”, provide details:
- COMPANY*
- LIMITS*
- DEDUCTIBLE*
- PREMIUM*
- EXPIRATION DATE*
  
  MonthDayYear
  Date
- RETRO DATE*
  
  MonthDayYear
  Date
- 4. Has any Professional Liability claim(s), complaint or proceeding been made against the Applicant or any person or organization proposed for this insurance or any predecessor organization in the past five (5) years?*
  
  YesNo
- 5. Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, error, omission, circumstance, or situation that might provide grounds for any claim under the proposed insurance?*
  
  YesNo
- If the answer to 4 or 5 is Yes, you will be required to complete the Supplemental Claims Questionnaire at the end of this application for each Claim, Notice, or Circumstance.
- 6. Does the Applicant discuss and document informed consent prior to treating all patients?*
  
  YesNo
- 7. Does the Applicant keep documented records on every visit of all treatment performed on patients, including discussions for follow-up care?*
  
  YesNo
- 8. Name of Institution where Applicant received Physical Therapist Training:*
- 9. Designation Received:*
- Graduation Date:*
  
  MonthDayYear
  Date
- THE APPLICANT WARRANTS THAT THE STATEMENTS AND RESPONSES TO THE QUESTIONS ON THIS APPLICATION ARE TRUE AND COMPLETE.
  THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY, NOR DOES IT OBLIGATE THE COMPANY TO ISSUE A POLICY. SUCH POLICY MAY BE CANCELLED BY THE COMPANY FROM INCEPTION UPON DISCOVERY THAT THE POLICY WAS OBTAINED THROUGH A FRAUDULENT STATEMENT, OMISSION, OR CONCEALMENT OF THE FACTS MATERIAL TO THE ACCEPTANCE OF THE RISK OR HAZARD ASSUMED.
- Date*
  
  MonthDayYear
  Date
- Applicant’s Authorized Signature*
  
  Clear
- a. Applicant Name*
- b. Name of the Claimant(s) or potential Claimant(s)*
- Date of the alleged act, error, or omission*
  
  MonthDayYear
  Date
- Is this a*
  
  ClaimLawsuitAdministrative/Disciplinary HearingIncident (potential claim)
- Is this matter settled?*
  
  YesNo
- If "Yes," what was the final disposition (monetary award, administrative sanction, etc.?)
- What was the total indemnity amount paid?*
- What were the total defense/legal costs paid?*
- If the matter is still pending, what remedy is being sought by the Claimant(s):
- c. Provide a brief description incident being reported*
- d. Was the Applicant insured under a Professional Liability policy at the time of the incident?*
  
  YesNo
- If "Yes", provide the insurance company name and policy number:
- THE APPLICANT WARRANTS THAT THE STATEMENTS AND RESPONSES TO THE QUESTIONS ON THIS APPLICATION ARE TRUE AND COMPLETE.
  
  THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY, NOR DOES IT OBLIGATE THE COMPANY TO ISSUE A POLICY. SUCH POLICY MAY BE CANCELLED BY THE COMPANY FROM INCEPTION UPON DISCOVERY THAT THE POLICY WAS OBTAINED THROUGH A FRAUDULENT STATEMENT, OMISSION, OR CONCEALMENT OF THE FACTS MATERIALTOTHE ACCEPTANCE OFTHE RISK OR HAZARD ASSUMED.
- Date*
  
  MonthDayYear
  Date
- Applicant's Authorized Signature*
  
  Clear
- Should be Empty:

1. Contact Information