ACORD 199 Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 196 (2008/03) Medical ProfessionalLiability InsuranceApplication Use ACORD 196, Medical Professional Liability Insurance Application, toapply for medical professional liability insurance coverage. The form is self-contained. It is not necessary to use ACORD 125,Commercial InsuranceApplication, with this application.
IDENTIFICATION SECTION Date (MM/DD/YYYY) Month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Producer’s name and address. In Florida and Nebraska, also include the producer’s state license number, and in Nebraska, add the agency state license number.
IDENTIFICATION SECTION Contact Name Indicate the name of the contact within the agency.
IDENTIFICATION SECTION Phone (A/C, No, Ext) Producer’s telephone number.
IDENTIFICATION SECTION Fax No. (A/C, No, Ext) Producer’s fax number.
IDENTIFICATION SECTION E-Mail Address Producer’s e-mail address.
IDENTIFICATION SECTION Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form.
IDENTIFICATION SECTION Subcode If the agency uses a sub-code identification system with the company, enter the appropriate code.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency.
IDENTIFICATION SECTION Carrier Name of the applicable insurance company. Do not use group names; use the actual name of the company within the group in which you wish to have the policy issued.
IDENTIFICATION SECTION NAIC Code Individual company code assigned by the NAIC.
IDENTIFICATION SECTION Applicant (First Named Insured) Full name of the applicant as it should appear on the policy. (The first named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first.) If joint ownership, the name used may include both names (e.g., John and Mary Smith). Wording such as “et al” or “As their interests may appear” is not acceptable as the name of the insured. These phrases do not designate legal entities.
IDENTIFICATION SECTION Social Security Number Enter the applicant’s social security number.
IDENTIFICATION SECTION DEA# (If applicable) Enter the applicant’s U.S. Drug Enforcement Administration (DEA) number, if applicable.
IDENTIFICATION SECTION US Citizen Check the applicable box.
IDENTIFICATION SECTION Date of Birth Enter the date of birth of the applicant (MM/DD/YYYY).
IDENTIFICATION SECTION Primary Business Address Enter the primary address of the business.
IDENTIFICATION SECTION Phone (A/C, No, Ext) Enter the telephone number of the applicant. Include area code and extension, if applicable.
IDENTIFICATION SECTION Mailing Address The address at which the first named Insured is to receive all correspondence regarding the insurance.
COVERAGES/LIMITS Claims Made Check the applicable box.
COVERAGES/LIMITS Occurrence Check the applicable box.
COVERAGES/LIMITS Aggregate Enter the desired aggregate limit.
COVERAGES/LIMITS Each Occurrence Enter the desired limit.
COVERAGES/LIMITS Other Enter the desired limit.
COVERAGES/LIMITS Proposed Effective Date Month/day/year on which the terms and conditions of the policy will commence. (MM/DD/YYYY)
COVERAGES/LIMITS Proposed Retroactive Date If a retroactive date is requested, enter the month/day/year. (MM/DD/YYYY)
PROFESSION Physician Check the applicable box.
PROFESSION Primary Practice Enter the primary practice of the applicant.
PROFESSION Secondary Practice Enter the secondary practice of the applicant, if applicable.
PROFESSION Surgeon Check the applicable box.
PROFESSION Specialty Enter the specialty of the surgeon, if applicable.
PROFESSION Other Enter the “other” option, if applicable.
PROFESSION Physician’s Assistant Check the applicable box.
PROFESSION Nurse Anesthetist Check the applicable box.
PROFESSION Surgeon’s Assistant Check the applicable box.
PROFESSION Psychologist Check the applicable box.
PROFESSION Nurse Midwife Check the applicable box.
PROFESSION Per fusionist Check the applicable box.
PROFESSION Registered Nurse Check the applicable box.
PROFESSION Licensed Practical Nurse Check the applicable box.
PROFESSION Optometrist Check the applicable box.
PROFESSION Emergency Medical Technician Check the applicable box.
PROFESSION Nurse Practitioner Check the applicable box.
PROFESSION Counselor Check the applicable box.
PROFESSION Other Check the applicable box. Describe “other” entity.
PERSONAL INFORMATION Type of Certification Currently Held Indicate the type of certification currently held by the applicant.
PERSONAL INFORMATION States in which You Actively Practice – State Enter the state postal code (XX) in which the applicant is licensed.
PERSONAL INFORMATION States in which You Actively Practice – License # Enter the license number.
EDUCATION (List Most Recent Attendance First) Institution Enter the name of the institution.
EDUCATION (List Most Recent Attendance First) Dates of Attendance – MM/YYYY Enter the starting date (MM/YYYY).
EDUCATION (List Most Recent Attendance First) Dates of Attendance – MM/YYYY Enter the ending date (MM/YYYY).
EDUCATION (List Most Recent Attendance First) Date Graduated Indicate the date of graduation (MM/YYYY).
EDUCATION (List Most Recent Attendance First) Certification or Degree Received Indicate the certification or degree received.
EDUCATION (List Most Recent Attendance First) ListContinuing Education Coursesand Credits Received Within the Last 2 Years List any continuing education courses and credits received within the last two (2) years or attach copies of certificates and/or credits received.
EDUCATION (List Most Recent Attendance First) Has your certification/license in any state ever been (voluntarily or otherwise) suspended, denied, revoked, restricted or limited in any way? Check the applicable box. If “YES”, explain.
EDUCATION (List Most Recent Attendance First) Current Practice Describe the general duties and extent of supervision, if any, of the applicant.
EDUCATION (List Most Recent Attendance First) List any Association/Memberships Related to your Profession List any Association/Memberships related to the applicant’s profession
EDUCATION (List Most Recent Attendance First) Present Employees and Positions List any present employees and positions employed by the applicant, if applicable.
LOSS HISTORY Enter All Claims (regardless of fault) or Occurrences that may give rise to Claims for the prior five (5) years (3 years in KS and NY)
LOSS HISTORY Check Here if None Check this box if there are no known losses and no occurrences that may lead to losses over the past five years for all lines of business being submitted.
LOSS HISTORY See Attached Loss Summary Check this box if a loss summary report is being sent with the application.
LOSS HISTORY Date of Occurrence Date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Type/Description of Occurrence or Claim A brief description of the loss.
LOSS HISTORY Date of Claim The date on which the loss or occurrence occurred.
LOSS HISTORY Amount Paid If the previous carrier has made any payments on this claim, enter the total amount paid to date.
LOSS HISTORY Amount Reserved If the claim is still open, list the reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Claim Status Indicate if this claim is open or closed by checking the applicable box.
AGENCY CUSTOMER ID Agency Customer ID Customer’s identification number assigned by the agency.
PRIOR CARRIER INFORMATION Carrier Name of the insurance company that wrote the policy.
PRIOR CARRIER INFORMATION Policy Number Enter the policy number exactly as it appears on the policy, including prefix and suffix symbols.
PRIOR CARRIER INFORMATION Retro Date If the policy was issued on a Claims Made basis and there was a retroactive date, list the date. If there was no date enter “none”.
PRIOR CARRIER INFORMATION Policy Type Indicate if the policy was claims made or per occurrence, by checking the applicable box.
PRIOR CARRIER INFORMATION Eff.- Exp. Date – Eff Date To: Show the effective date of the policy.
PRIOR CARRIER INFORMATION Eff.- Exp. Date – Exp Date From: Show the expiration date of the policy.
PRIOR CARRIER INFORMATION General Aggregate Enter the aggregate limit.
PRIOR CARRIER INFORMATION Occurrence Enter the limit per occurrence.
GENERAL INFORMATION Explain all “Yes” Responses Use the space below each question to provide additional information for any questions answered with a “Yes” response.
GENERAL INFORMATION 1. Have you ever been insured by Mutual Assurance or Medical Assurance for professional liability? Enter Y for a “YES” response. Enter N for a “NO” response. If “YES”, enter the policy number or previous employer.
GENERAL INFORMATION 1. Policy Number Enter the policy number exactly as it appears on the policy, including prefix and suffix symbols.
GENERAL INFORMATION 1. Previous Employer If policy number is not known, enter the name of the previous employer.
GENERAL INFORMATION 2. If professional liability coverage is provided through your employer, do you maintain a separate policy for professional liability? Enter Y for a “YES” response. Enter N for a “NO” response. If “YES”, provide a copy of your Declarations page. A Certificate of Insurance may also be required. Check with the carrier.
GENERAL INFORMATION 3. Have you ever been diagnosed with or professionally advised to seek medical treatment for alcohol/drug abuse or addiction, mental illness or chronic physical illness. Enter Y for a “YES” response. Enter N for a “NO” response. If “YES”, describe.
GENERAL INFORMATION 4. Have any fee or professional relation complaints been registered against you with your professional association(s), hospital(s) or any state licensing authority? Enter Y for a “YES” response. Enter N for a “NO” response. If “YES”, describe.
GENERAL INFORMATION 5. Have you ever been charged with or convicted of a criminal offense? Enter Y for a “YES” response. Enter N for a “NO” response. If “YES”, describe.
GENERAL INFORMATION 6. Has your professional liability insurance ever been cancelled, suspended, non-renewed, declined or issued only on special terms? Enter Y for a “YES” response. Enter N for a “NO” response. If “YES”, describe. This question cannot be asked in Missouri.
GENERAL INFORMATION 7. Are you a subsidiary of another entity or do you have any subsidiary? Enter Y for a “YES” response. Enter N for a “NO” response. If “YES”, describe.
SIGNATURE Producer’s Signature Upon completion of the application, the producer should review and sign this form in the available space.
SIGNATURE Producer’s Name Print or type the full name of the producer.
SIGNATURE State Producer License No Enter the State Producer License Number. This information is required in Florida.
SIGNATURE Applicant’s Signature Upon completion of the application, the insured should review the application and sign this form in the available space.
SIGNATURE Date Date the application was signed.
SIGNATURE National Producer Number Number assigned to the producer by the NAIC.