Professional Liability Insurance Form - Medical Institution

PROFESSIONAL LIABILITY INSURANCE PROPOSAL

FOR MEDICAL INSTITUTION

THIS PROPOSAL IS TO BE COMPLETED BY THE PROPOSER OR AN AUTHORIZED REPRESENTATIVE OF THE PROPOSER. ALL QUESTIONS SHOULD BE ANSWERED FULLY AND ACCURATELY.

SIGNING OF THIS PROPOSAL DOES NOT BIND THE COMPANY TO OFFER, NOR THE PROPOSER TO ACCEPT INSURANCE. BUT IT IS AGREED THAT THIS PROPOSAL SHALL BE THE BASIS OF ANY INSURANCE ISSUED. NO INFERENCE SHOULD BE MADE, HOWEVER, FROM THE INCLUSION OF ANY QUESTION IN THIS PROPOSAL THAT THE SUBJECT MATTER TO WHICH THAT QUESTION RELATES WILL BE COVERED UNDER THE POLICY. THE POLICY TERMS ARE ONLY AS STATED IN THE POLICY WHICH SHOULD BE READ CAREFULLY.

ATTENTION IS DRAWN TO THE PROPOSER’S OBLIGATIONS AT LAW TO DISCLOSE ALL METERIAL FACTS WHICH WOULD AFFECT THE ISSUANCE OF THE PROPOSED INSURANCE.

If there is insufficient space to complete the proposal, please continue on your headed paper.

1.      Proposer (to be named as Insured if is issued)

1.1    Name                                                   :

1.2    Address                                               :

1.3    Location of all premises                   :

1.4    The proposer is a (n)                         :

ٱ          Individual              ٱ           Joint Venture        ٱ           Partnership

ٱ          Organization (other than Partner-ship or Joint Venture)

             

1.5    Date of establishment                      :

1.6    Is the proposer registered as a charity?

2.      Institution to be insured

2.1.   Description of institution

Please attached literature, brochures, annual reports

2.2.   During the part five years, has the name of the proposer been changed or has any other firm been purchased by the proposer or has any merger or consolidation involving the proposer taken place?

ٱ         No           ٱ           Yes

If yes, please give full details:

__________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

2.3.   Chief physicians and surgeons, heads of departments:

Name	Age	Qualifications	Date qualified	How long practicing with
				Proposer ?	Previous institution ?

2.4.   Have any of the practioners practising at this institution ever been subject to professional disciplinary action?         ٱ               No             ٱ           Yes

If yes, please give full details on your letter headed paper

2.5.   Has the proposer recently discharged any of the staff or severed any relationships with any person in charge or is such discharge or severance being contemplated?

ٱ            No           ٱ           Yes

If yes, please give full details on your letter headed paper

2.6.  Has the proposer ever had its license revoked?         ٱ               No           ٱ           Yes

If yes, please give full details on your letter headed paper

____________________________________________________________________________

                   ____________________________________________________________________________

3.      Limits of Insurance Requested

A.      Each Incident Limit                          :               _________________________________________

B.      Aggregate Limit each policy year :               _________________________________________

4.      Insured’s Retained Amount Requested

4.1.		Per claimant with respect to each incident
4.2.		Per each incident

5.      Policy Period Requested

5.1.    From the	Day of		20		(Inception Date)
5.2.    To the	Day of		20		(Expiration Date)

If the policy period is at least one year it will automatically be continued in accordance with Section 5.2. of the policy unless cancelled before the Expiration Date.

6.      Scope of Coverage

The scope of coverage is determined by the standard Asuransi Jasindo’s Professional Liability Insurance Policy, and the Profession Endorsement to be included in such policy.

Does the proposer request any of the following extensions?

	NO	YES
Prior Acts Endorsement

7.      Proposer’s Services

Proposer’s institution renders services as a:

		NO	YES
A.	Clinic
B.	Convalescent or nursing home
C.	Hospital
D.	Laboratory-dental,medical, x-ray*
E.	Mental – psychopatic institution
F.	Other services rendered, please specify:

* if laboratory’s services are rendered to others than proposer’s patients, please fill in question 8.

With a(n):

		NO	YES
A.	Intensive care unit
B.	Emergency department
C.	Radiotherapy unit
D.	Medical teaching facility

8.      For Laboratories Only

8.1.     Please give gross fees for the current and last three years:

Year	Annual gross fees received
Current year
20 ___
20 ___
20 ___

8.2.     Proposer’s services rendered, please specify

______________________________________________________________________________________________________________________________________________________

9.      Total Number of Personnel

		Employed Practitioners	Non-Employed Practitioners	Total Number
A.	Chief physicians & surgeons, head of departments
B	Doctors (other than A)
C.	Surgeons (other than A)
D.	Nurses, physiotherapist, lab. Technicians, etc
E.	Other assistants
F.	Other staff, omitting ancillary staff such as cleaners, maintenance personnel and the like

Please note that the policy does not provide coverage for independent practitioners, not employed by the institution.

10.   Number of Beds

10.1.	How many patient beds are available?
10.2.	Annual average occupancy rate, in percentage	%

11.   Outpatient Visits

Please give number of outpatients treated

_________________________________________________________________________________

12.   Employed Practitioners’ Division of Work

Please select present specialty/ subspeciality of the proposer’s employed practitioners from the list below and give the corresponding number:

Description	Number		Description	Number
Acupuncturist			Otorhinolaryngologists
Allergists			Pathologist
Anesthesiologists			Pediatricians
Broncho-Esophagologists			Physicians – General Practitioners
Cardiologists			Physiotherapists
Chiropractors			Podiatrists
Dentists			Psychiatrists
Dermatologist			Psychoanalysts
Emergency Medicine			Psychosomatic Medicine
Endocrinologist			Radiologists
Gynecologists			Rheumatologists
Hematologists			Rhinologists
Internal Medicine			Roentgenologists
Laryngologists			Surgeons – cardiovascular disease
Legal/ Forensic Medicine			Surgeons – cosmetic/ plastic
Lung/ Chest Specialists			Surgeons – gynecology/ obstetrics
Midwives			Surgeons – internal medicine
Miscellaneous Practitioners- NOC			Surgeons – neurology
Nephrologists			Surgeons – ophtalmology
Neurologists			Surgeons – oral and dental
Nuclear Medicine			Surgeons – orthopedic
Nurses			Surgeons – otorhinolaryngology
Obstetricians			Surgeons – general – NOC
Ophtalmologists			Urologists
Optpmetrists			Veterinarians
Orthodontists			Others, please specify:
Otologists
			TOTAL

13.   Loss Experience

Please indicate below all losses paid or now reserved (whether or not resulting in claims) occurring during the past five years :

Year	Total No. of Claims	Amount  Paid	O/S Claims Reserves
20
20
20
20
20

Please give full details of all major losses:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13.1.     Are there any claims currently pending against the Proposer or is the Proposer aware.

AFTER INQUIRY, of any circumstances which could give rise to a claim under the proposed insurance?                ٱ               No          ٱ           Yes

If yes, please give full details:

___________________________________________________________________________

___________________________________________________________________________

14.   Prior Insurance

14.1.     Please give full details of Proposer’s liability insurance coverage for the past five years :

Year	Carrier	Policy No.	Limits of Prior Insurance
			Professional Liability Each Incident / Annual Aggregate		General Liability Each Occurrence  Annual Aggregate
			/		/
			/		/
			/		/
			/		/
			/		/

14.2.     The current professional liability insurance policy provides:

	No prior acts coverage		Unlimited prior acts coverage
	Prior acts coverage with retroactive (or limitation) date of

14.3.     Has any insurer ever declined or cancelled or refused to renew insurance or required reduced limits or imposed special terms?

ٱ         No           ٱ           Yes

If yes, please give full details, including name of insurer:

______________________________________________________________________________________________________________________________________________________

I/ We, the undersigned, declare that to the best of my/ our knowledge and belief the statements set forth herein are true and correct, and agree that this proposal and any supplementary information requested by the company and furnished in connection herewith shall form the basis of and be incorporated into any contract of insurance which may be concluded between the Proposer and the Company.

I/ We undertake to inform underwriters of any material alteration to these facts occurring before completion of the contract of insurance.

(Place, Date)		(Stamp and Signature)