NOTICE
THIS IS AN APPLICATION FOR AN INSURANCE POLICY TO BE ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE FOR YOUR RISK RETENTION GROUP.
WASHINGTON HEALTHCARE INSURANCE COMPANY, A RISK RETENTION GROUP IS A DBA: OF CALIFORNIA HEALTHCARE INSURANCE COMPANY, INC., A RISK RETENTION GROUP
THE STATEMENT AND REPRESENTATIONS MADE HEREIN BY THE APPLICANT ARE WARRANTED TO BE TRUE AND COMPLETE, AND IT IS UNDERSTOOD THAT IF A POLICY OF INSURANCE IS ISSUED, IT WILL BE ISSUED IN RELIANCE UPON THE TRUTH OF SUCH REPRESENTATIONS AND THAT THIS APPLICATION WILL FORM A PART OF THE POLICY ISSUED.
NOTICE
THIS IS AN APPLICATION FOR AN INSURANCE POLICY TO BE ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE FOR YOUR RISK RETENTION GROUP.
IDAHO HEALTHCARE INSURANCE, A RISK RETENTION GROUP IS A DBA: OF CALIFORNIA HEALTHCARE INSURANCE COMPANY, INC., A RISK RETENTION GROUP
THE STATEMENT AND REPRESENTATIONS MADE HEREIN BY THE APPLICANT ARE WARRANTED TO BE TRUE AND COMPLETE, AND IT IS UNDERSTOOD THAT IF A POLICY OF INSURANCE IS ISSUED, IT WILL BE ISSUED IN RELIANCE UPON THE TRUTH OF SUCH REPRESENTATIONS AND THAT THIS APPLICATION WILL FORM A PART OF THE POLICY ISSUED.
NOTICE
THIS IS AN APPLICATION FOR AN INSURANCE POLICY TO BE ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE FOR YOUR RISK RETENTION GROUP.
OREGON HEALTHCARE INSURANCE COMPANY, A RISK RETENTION GROUP IS A DBA: OF CALIFORNIA HEALTHCARE INSURANCE COMPANY, INC., A RISK RETENTION GROUP
THE STATEMENT AND REPRESENTATIONS MADE HEREIN BY THE APPLICANT ARE WARRANTED TO BE TRUE AND COMPLETE, AND IT IS UNDERSTOOD THAT IF A POLICY OF INSURANCE IS ISSUED, IT WILL BE ISSUED IN RELIANCE UPON THE TRUTH OF SUCH REPRESENTATIONS AND THAT THIS APPLICATION WILL FORM A PART OF THE POLICY ISSUED.
If "Yes" please complete Attachment A
I, the undersigned, hereby declare that all answers and statements herein given are true and complete to the best of my knowledge and I have not omitted or withheld any fact or circumstance, which would be relied upon in the determination by the insurance company indicated on this application in granting liability insurance. I understand that this application, and any documents provided are made part of the policy that is issued.
I authorize any state board examiners or licensers, hospital board or committee, insurance company, professional society, past or present business or medical associate or private person that may have any record or knowledge concerning any of the answers or statements made herein to release such information to the insurance company or its assigns. I authorize the use of a copy of this acknowledgement in lieu of its original.
I understand that my Professional Liability insurance will be written on a “Claims-Made form” and acknowledge that this coverage will only respond to claims which are reported during the term of this policy. I also acknowledge that my “Claims-Made” coverage will not provide insurance coverage for claims which occurred prior to the “”Prior Acts Date” of my policy.
I understand that, should my “Claims-Made” policy with this insurance company ever be cancelled or non-renewed, for reasons other than non-payment of the premium, or if I decide to terminate the policy for any other reasons, I can elect to purchase an Extended Reporting Period (“Tail”) Endorsement subject to the policy terms and conditions. An Extended Reporting Period Endorsement provides protection for any claims which may have occurred during the term of the “Claims-Made” policy, but were not reported to the insurance company before the date of the policy termination.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. (For Oregon only: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing materially false or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, may commit a fraudulent insurance act, which may be a crime and may be subject to civil fines and criminal penalties.) (For Washington, Idaho and Tennessee residents only: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.) (For Arizona residents only: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.)
Please complete one Attachment A for each claim or suit alleging malpractice that was brought against you. Answer in adequate detail to allow proper evaluation. Attach copies of patient’s charts, operative notes or other documents as appropriate.
I understand this information is part of my Professional Liability Insurance Application.
Please complete one Attachment A for each claim or suit alleging malpractice that was brought against you. Answer in adequate detail to allow proper evaluation. Attach copies of patient’s charts, operative notes or other documents as appropriate.
I understand this information is part of my Professional Liability Insurance Application.
If you are not re-directed to a page that says “Thank you for filling out the form. You will receive an e-mail shortly” then please scroll through your application to check for required fields that are not completed. Required fields are highlighted in red.