Complete Podiatry Application

*General anesthesia means a pharmacological or non-pharmacological method, or a combination thereof, intended to cause a controlled state of unconsciousness, accompanied by partial or complete loss of protective reflexes, including the inability to independently maintain an airway and respond purposefully to physical stimulation or verbal command.

Please complete a Loss Information Supplement for each written request, incident, claim or suit (A, B or C) in which the group, entity and/or individual's policy was triggered. Download the Loss Supplemental Form here.

Report professional liability, malpractice and related matters for each applicant (including but not limited to, board complaints, etc.)

For Questions B. and C. below, report all matters that might reasonably lead to a claim or suit being brought against the group, entity, and/or anyone from your practice, even if it is believed the claim or suit would be without merit.

MANDATORY: ALL APPLICANTS must read and initial the following:

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 information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties, which may include voiding of the policy if allowed by state law.

By my signature, I hereby represent that all applicants have granted me full authority to execute this application on his, her or the entity’s behalf and I am authorized to represent and sign on behalf of anyone from my practice. I also represent that I have reviewed the responses contained in this application with the applicants, and we are in agreement they are full and complete to the best of our combined knowledge and belief. In addition, I represent that I have discussed the representations provided throughout this application with the applicants and that they understand and agree that such representations are binding upon him, her or the entity, even though I am executing this application on the applicant’s behalf.

I further acknowledge that the above statements and particulars, or any statements and particulars made in any and all documents, applications, supplemental pages or other attachments (hereinafter “Attachments”) for the purposes of my, or any applicants’ initial or renewal application, are true and that I, nor any applicant, have not knowingly suppressed or misstated any material facts and I, and any applicant, agree that this application, and any Attachments, shall be the basis of the contract with the Company. I agree to notify the Company if there are any future material changes in arrangement with any other healthcare professional, facility, firm or professional association.

I understand that any material misrepresentation or omission made by me may act to render any contract of insurance null and void and without effect or provide the Company the right to rescind it. By making this application, I am not, nor is any other applicant relying upon any oral or written representation that coverage has or will be extended or that a policy of insurance will be issued.

I understand and agree that a credit report and/or a credit score may be obtained, reviewed or used in connection with the submission of this application. I understand and agree that the credit information may be used to develop a credit-based insurance score, and may also be provided to a third party for the purpose of evaluating this application or to assist in the development of a credit-based score.

I further understand and agree that I have no right to demand or expect coverage until the Company has: (1) received the completed application(s); (2) offered a premium quote; and (3) received, as a precondition to coverage, the total premium due or, if the Company has agreed to finance the premium, the first installment due. In addition, I or any applicant understands that if payment of premium or first installment is by check, electronic transfer or money order, it shall not be considered “received” by the Company until it has been honored by the bank.

I AGREE THAT IT I FAIL TO COMPLY WITH THESE TERMS WE WILL HAVE NO COVERAGE FOR ANY CLAIM UNDER ANY POLICY OF INSURANCE FOR WHICH WE ARE APPLYING.

I understand that the Company may wish to contact persons, hospitals, schools, employers, insurance agents, professional liability insurers or other entities to verify and/or ascertain information regarding credentials and background both prior to and if issued, after the issuance of a contract of insurance. Therefore, I hereby instruct any such person, hospital, school, employer, insurance agent, professional liability insurer or other entity to release to the Company any information regarding me or any applicant, which the Company, in good faith, believes to be applicable and pertinent to this application and if issued, the contract of insurance issued hereunder.

By signing this application on behalf of a group, or an entity (which may include a professional corporation, a professional association, a limited liability company, a general business corporation, a partnership, a joint venture, or a governmental entity), I warrant that I am and Officer, Shareholder, Partner, or other Authorized Representative of the group or entity applying for coverage.

I warrant that I am authorized to disclose all information that I may submit or which I may authorize other to submit in connection with this application, including authority to disclose such information under federal and state privacy protection statutes and regulations.

Application must be signed by the Individual Applicant, a President, Chief Executive Officer, or other Officer, Shareholder, or Partner of a PC or PA, or the equivalent Authorized Representative.