• MED TECH APPLICATION

    MED TECH APPLICATION

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Expiration Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Bill Type
  • Type of Business
  • Do you operate out of a retail store that is open to the public?

  • Do you repair, service, rent or sell any of the following equipment:

  • Cardiopulmonary Bypass
  • Life Support Ventilation
  • Defibrillators
  • Implants
  • Ventrical Assistance
  • Pacemakers
  • * If you replied yes, please indicate which type of defibrillator
  • Please indicate any certifications you hold below:
  • Has your certification ever been revoked or suspended?

  • Indicate the estimated premium basis for the new policy year below:

  • 1. Any sales, service, repair, rental or manufacturing of non-medical equipment?
  • 2. Do you import component parts?
  • 3. Do you export products or have foreign operations?
  • 4.Are any of your products or services subject to registration/regulation/review by any government agency?
  • 5. Do you manufacture, assemble, or package products?
  • 6. Do others manufacture, assemble, package, or install products under your name or label?
  • 7. Do you use subcontractors to repair or service medical devices or machines?
  • 8.Do you subcontract any electrical or plumbing work?
  • A. Do you require sub-contractors to provide Certificates of Insurance with general liability limits equal to yours?
  • B. Do you require that sub-contractors list you on their general liability policy as an Additional Insured?
  • C. Do you require a written contract with all sub-contractors that includes a hold harmless agreement?
  • 9 . Do you anticipate any changes in your operation, including the discontinuing of any service or product now offered?
  • 10. Has any insurer ever canceled, restricted or refused to renew your products liability insurance?
  • THREE YEAR PREMIUM & LOSS HISTORY
    Rows

  • Commercial General Liability Coverage

  • General Aggregate

  • $2,000,000

  • Each Occurrence

  • $1,000,000

  • Products & Completed Operations

  • $2,000,000

  • Personal & Advertising Injury

  • $1,000,000

  • Damage to Rented Premises (each occurrence)

  • $100,000

  • Medical Expense (Any one person)

  • Excluded

  • Completion

  • NOTICE OF INSURANCE INFORMATION PRACTICES. In connection with this application for insurance (and subsequent policy renewals), your personal information may be collected from persons other than you and without your authorization (e.g., credit reports You have the right to review your personal information in our files and may request correction of any inaccuracies contained therein. A more detailed description of your rights and our practices regarding such information will be available upon request and you may contact your agent or broker for instructions regarding how to submit this request to us.

    Any person who knowingly files an application for insurance or a statement of claim with materially false information with the intent to defraud an insurance company or another person is committing a fraudulent insurance act. Moreover, any person who has concealed material facts for the purpose of providing misleading information is also committing a fraudulent insurance act. These acts are crimes and subjects the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, FL, HI, MA, NE, OH, OR, or VT; in DC, LA, ME, TN, VA and WA insurance benefits may also be denied In Florida, it is a third degree felony to knowingly file a statement of claim or any application containing false, incomplete, or misleading information with the intent to injure, defraud and/or deceive any insurer.

    The undersigned is an authorized representative of the applicant and acknowledges that reasonably inquiry has been made to obtain the information on this application. He/she acknowledges that the answers are true, correct and complete to the best of his/her knowledge.

  • Producer's Signature

  • Applicant's Signature

  • Should be Empty: