Evanston Insurance Company
  Markel American Insurance Company
  Markel Insurance Company

		
PODIATRISTS PROFESSIONAL LIABILITY INSURANCE
(Claims Made Basis)
APPLICANT’S INSTRUCTIONS:
1.  Answer all questions. If the answer requires detail, please attach a separate sheet.
2.  Application must be signed and dated by owner, partner or officer.
3.  If you have Curriculum Vitae (C.V.), please attach to application and check here [   ].
4.  Please do not complete application earlier than 45 days before proposed effective of coverage.
5.  PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION.
(PLEASE TYPE OR PRINT IN INK)
1.	APPLICANT INFORMATION
	a.	(i)	Full Name of Applicant: 	  Date of Birth: 	
		(ii)	Home Address:  	  Phone: (      ) 	
	b.	(i)	Principal business premise address: 		
	(Street)		(County)
	
			(City)	(State)	(Zip)
	Phone: (      ) 	
		(ii)	Other Offices: 	  Phone: (      ) 	
				  Phone: (      ) 	
	c.	Limits of Liability desired:  100,000/300,000    250,000/750,000    500,000/1,500,000    1,000,000/3,000,000
	d.	Federal DEA Number: 	
	e.	Your practice is:  [    ] Solo Practitioner (unincorporated)     [     ] Solo Practitioner (incorporated)     [     ] Partnership
[    ] Member of a group corp.     [    ] Other (describe	
	f.	If your practice is a partnership, group corporation, or association, or employ any physicians, please complete the following:
		(i)	Please list the names of ALL other partners, stockholders, associates and employed physicians; and indicate the status of each:
			(a) 		(d) 	
			(b) 		(e) 	
			(c) 		(f) 	
	g.	Is the Applicant a “Covered Entity” under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule?	[   ] Yes  [   ] No
If Yes,
(i)	Has the Applicant implemented procedures to comply with the HIPAA Privacy Rule?	[   ] Yes  [   ] No
(ii)	Provide the name and title of the Applicant’s Privacy Officer.	
Our Business Associate Agreement is available at https://www.markelcorp.com/US-Insurance/HIPAA. This is the only Business Associate Agreement we will recognize.
2.	PRACTICE
	a.	Please list all states where you are licensed to practice:
		State: ____________________________________	License Number: 	
		State: ____________________________________	License Number: 	
		State: ____________________________________	License Number: 	
	b.	Do you practice:   [    ] Full-time    [    ] Part-time    _____________ hours per week
	c.	Please list all locations where you have practiced in the last ten years:
		Name of Facility: _______________________________ Address: ___________________________ Year(s): _____
		Name of Facility: _______________________________ Address: ___________________________ Year(s): _____
		Name of Facility: _______________________________ Address: ___________________________ Year(s): _____
	d.	(i)	Average patient load:   __________________ Pts. Weekly   _____________________ Total pts. Annually
		(ii)	Please indicate the number of days you work per week: _______________
		(iii)	Please indicate the number of practice hours per day: _____________ per week: ______________
	e.	Please provide a list of all professional health care personnel employed by or under contract with you or your entity.  (If insured, please furnish the name of the insurance carrier and the policy number.)
		Name	Job Category	Professional Liability Insurance

			
	f.	Please list hospitals/surgery centers at which you are currently a staff member and show % of work at each location.  Also submit copies of staff privileges.  (If you request a Certificate of Insurance to be sent, please circle the number of the hospital/surgery center.)
		1) _________________________________________________________	_____________%
		2) _________________________________________________________	_____________%
		3) _________________________________________________________	_____________%
		4) _________________________________________________________	_____________%
	g.	Are you affiliated in any capacity with any of the following:
		(i)	Any healthcare facility having bed and board accommodations?	[   ] Yes  [   ] No
		(ii)	Any clinic, foundation, blood bank or laboratory?	[   ] Yes  [   ] No
		(iii)	Any health maintenance organization (HMO), preferred provider organization 
			(PPO), individual physicians’ association, and/or any pre-paid health plan, etc.?	[   ] Yes  [   ] No
		PLEASE PROVIDE THE FOLLOWING FOR ANY “YES” ANSWERS:
		1)	Please give the full legal name and location of the facility as well as the department in which you serve: 	
				
		2)	Does the above facility provide insurance coverage for this work?	[   ] Yes  [   ] No
		3)	Please indicate your affiliation:
			__________  Owner (whole or part)	__________  Committee Member
			__________  Executive Officer (e.g., Board Member)	__________  Director – Dept. of Ancillary Services
			__________  Physician with teaching responsibilities	__________  Administrator
			__________  Other (please describe): ___________________________
		4)	How are you compensated for your services? [  ] Salary  [  ] Percentage  [  ] Fee for Service [  ] Honorary or non‑paid
		5)	What type of contractual agreement do you have?  [   ] Oral   [    ] Written
		6)	Please indicate the number of practice hours per day: _______________   per week: 
	h.	Do you practice any of the following:
		Sports Medicine	[   ] Yes  [   ] No
		Minimal Incision Surgery	[   ] Yes  [   ] No
		Emergency Room work	[   ] Yes  [   ] No
		Laser Surgery	[   ] Yes  [   ] No
(i)	For what type of treatment do you use the laser? 	
		(ii)	How many times per week do you perform laser surgery? 	
		(iii)	Please indicate the type of training you received in laser surgery.  Please check all that apply:
			[    ] Seminar    [    ] Course    [    ] Hands On    [    ] Preceptorship    [    ]Other
			Please specify the name(s) of program(s): 	
3.	PROCEDURES
	a.	Please complete the following list of procedures performed, adding any others in the space provided below.
Instructions:  In column 1, please check each procedure performed.
In column 2, please list the number of times the procedure has been performed within the past two years.
In column 3, please use “O” or “H” to indicate whether in an office or hospital.
In column 4, please indicate the number of office procedures that would be considered “minimal incision surgery.”
Name of Procedure	1	2	3	4		Name of Procedure	1	2	3	4	
Fulguration of verrucae	[  ]	____	____	____		Osteotomies with fusion-digits-Metatarsal heads	[  ]	____	____	____	
Curettage of verrucae	[  ]	____	____	____		Implants	[  ]	____	____	____	
Excision of verrucae	[  ]	____	____	____		Aneurysm	[  ]	____	____	____	
Avulsion of toenail	[  ]	____	____	____		Tendon transfer (digital)	[  ]	____	____	____	
Onychoplasty	[  ]	____	____	____		Tendon transfer (other)	[  ]	____	____	____	
Onychotripsy	[  ]	____	____	____		Tendo Achilles lengthening	[  ]	____	____	____	
Subungual exostosectomy	[  ]	____	____	____		Repair of ruptured tendon	[  ]	____	____	____	
I & D of superficial abscess	[  ]	____	____	____		Tenodesis	[  ]	____	____	____	
Plantar lesion - skin	[  ]	____	____	____		Tendon transplant	[  ]	____	____	____	
Tendotomy - digital tendon
  (exterior flexor)	[  ]	____	____	____		Capsulotomy - rear foot	[  ]	____	____	____	
Capsulotomy - forefoot	[  ]	____	____	____		Repair of syndactylism	[  ]	____	____	____	
Arthroplasty	[  ]	____	____	____		Repair of polydactylism	[  ]	____	____	____	
Phalangectomy	[  ]	____	____	____		Amputation	[  ]	____	____	____	
Closed reduction (digital)	[  ]	____	____	____		Panmetahead resection	[  ]	____	____	____	
Open reduction (digital)	[  ]	____	____	____		Excision of metatarsal	[  ]	____	____	____	
Tendon Lengthening - digital	[  ]	____	____	____		Excision of trigonum	[  ]	____	____	____	
Soft tissue tumors - rear foot	[  ]	____	____	____		Excision of tarsal bone	[  ]	____	____	____	
Osteoclasis	[  ]	____	____	____		Closed reduction - rear foot	[  ]	____	____	____	
Foreign bodies - forefoot	[  ]	____	____	____		Open reduction - other	[  ]	____	____	____	
Excision of accessory ossicles	[  ]	____	____	____		Metatarsal tarsal fusions
 (MP-MT joints)	[  ]	____	____	____	
Metahead resection (partial or complete)	[  ]	____	____	____		Arthrodesis of tarsus	[  ]	____	____	____	
Excision of sesamoids (1st MP)	[  ]	____	____	____		Skin graft	[  ]	____	____	____	
Resection of metatarsal exostosis	[  ]	____	____	____		Repair of osteomyelitis	[  ]	____	____	____	
Closed reduction (metatarsal)	[  ]	____	____	____		Bone cysts and tumors	[  ]	____	____	____	
Terminal Syme (lesser digitals)	[  ]	____	____	____		Cavus foot correction	[  ]	____	____	____	
Excision of nevi	[  ]	____	____	____		Flatfoot correction	[  ]	____	____	____	
Soft tissue tumors - forefoot	[  ]	____	____	____		Metatarsal adductus correction	[  ]	____	____	____	
Terminal syme (hallux)	[  ]	____	____	____		Reconstruction of anomaly	[  ]	____	____	____	
Hemangioma - excision of	[  ]	____	____	____		Ankle Arthroscopy	[  ]	____	____	____	
Plastic repair of skin - rear foot	[  ]	____	____	____		ORIF Ankle Fracture	[  ]	____	____	____	
Repair of ruptured ligament-forefoot	[  ]	____	____	____		Tarsal tunnel decompression	[  ]	____	____	____	
Planter fasciotomy and heel spurs	[  ]	____	____	____		Ankle Arthrodesis	[  ]	____	____	____	
Excision of plantar fibromatosis	[  ]	____	____	____		A-O fixation	[  ]	____	____	____	
1st metahead resection (partial or complete)	[  ]	____	____	____		Ankle Stabilization	[  ]	____	____	____	
Hallux valgus repair (1st MP only)	[  ]	____	____	____		Perform surgery on ankle 
Joint and lower leg?	[  ]	____	____	____	
Partial resection of hypertrophied tarsal bone	[  ]	____	____	____		Perform surgery on tendoachilles?	[  ]	____	____	____	
Heel spur resection	[  ]	____	____	____		Do you provide post-operative care?	[  ]	____	____	____	
Digital Fusions IP joints	[  ]	____	____	____		Do you provide routine foot care in patients of any age that satisfy Medicare high-Risk criteria?	[  ]	____	____	____	
Use of K Wire-staples-implants-wire for fixation	[  ]	____	____	____		Other procedures performed:
_______________________	[  ]	____	____	____	
Joint or other implants or prostheses made of materials capable of degradation, erosion, fragmentation, and/or the provocation of inflammatory tissue reactions?	[  ]	____	____	____							
	b.	Do you administer anesthesia
		(i)	Intravenous?	[   ] Yes  [   ] No
		(ii)	Local?	[   ] Yes  [   ] No
		(iii)	Nitrous Oxide?	[   ] Yes  [   ] No
		(iv)	Other (describe) ________________________________________________________
4.	HISTORY
	a.	Attach a detailed explanation with dates for any “Yes” answers:
		(i)	Have you ever been convicted of a felony?	[   ] Yes  [   ] No
		(ii)	Have you ever had professional liability insurance declined, canceled, issued on special
			terms or non-renewed?	[   ] Yes  [   ] No
		(iii)	Have you ever been investigated by a State Board of Medical Examiners, Narcotics
			Board, or other licensing or governmental regulatory agency?	[   ] Yes  [   ] No
		(iv)	Has your membership in any professional society or association ever been refused,
			censured, suspended or revoked?	[   ] Yes  [   ] No
		(v)	Have you ever had privileges at a hospital or surgery center reduced, revoked, restricted 
			or suspended?	[   ] Yes  [   ] No
		(vi)	Have you now or ever had any chronic disability or had an interruption of your practice
			due to disability?	[   ] Yes  [   ] No
		(vii)	Have you ever used any intoxicant, narcotic, or other psychoactive drug to the extent
			that it has interfered with your ability to perform professional duties?	[   ] Yes  [   ] No
		(viii)	Have you ever been involved in a drug or alcohol diversion or rehabilitation program? 	[   ] Yes  [   ] No
		(ix)	Have you ever been suspended by any governmental health program (e.g., Medicare)?	[   ] Yes  [   ] No
	b.	Please list malpractice coverage for the past ten years:
			Dates Covered	Claims
		Name of Insurer	From   -   To	Open        Closed        Total
		1) 					
		2) 					
		3) 					
		4) 					
		5) 					
	c.	If prior professional liability insurance was on a claims made basis, please indicate the retroactive exclusion date of coverage 	
5.	CLAIMS
	a.	Has any physician, patient or insurance plan ever filed a complaint against you with any 
		Medical Association/Society or Foundation, Consumer Protection Agency, Chamber of 
		Commerce or Better Business Bureau?	[   ] Yes  [   ] No
		If yes, please complete a Claims Information form for each case.
	b.	Are you aware of any facts or circumstances which may give rise to a claim or suit?	[   ] Yes  [   ] No
		If yes, please complete a Claims Information form for each case.
	c.	Have you ever been involved in a malpractice claim or suit, either directly or indirectly, or are 
		you presently involved in malpractice litigation?	[   ] Yes  [   ] No
		If yes, please complete a Claims Information form for each case.
6.	COVERAGE
	a.	Non-surgical, Podiatry, Category 1   [    ] Yes   [    ] No
Limitation Provision One - coverage DOES NOT APPLY (except in an emergency requiring immediate and unexpected intervention) to injury arising out of any professional service listed below:
(i)	The administration of anesthesia other than topical or by means of local infiltration;
(ii)	The reduction of any fracture;
(iii)	The use of lasers;
(iv)	The administration of nitrous oxide-oxygen inhalation analgesia. (v)	Assisting in the performance of any podiatric surgical procedure; and
(vi)	The performance of any procedure involving the cutting or penetration of any tissue, except:
	1.	Incision and/or drainage of sebaceous cysts, abscesses, or hematoma;
2.	Curettage of verrucae;
3.	Incision and removal of foreign body from the superficial or subcutaneous tissue;
4.	Debridement of infected skin, abrasions or keratotic lesions;
5.	Debridement, excision or avulsion of nail plate, excluding permanent removal except those procedures which involve the use of electrical or chemical cautery;
6.	Needle penetration of the skin and blood vessels;
7.	Treatment of burns except the local treatment of third degree burns;
8.	Closed manipulative reductions of fractures of metatarsals and phalanges.
	b.	Intermediate Surgery    [     ] Yes   [    ] No
Limitation Provision Two - Coverage DOES NOT APPLY (except in an emergency requiring immediate and unexpected intervention) to injury arising out of any professional service listed below:
(i)	Treatment or reduction of compound fractures of the calcaneus or talus;
(ii)	Triple arthrodesis;
(iii)	Surgical procedures of the ankle joint which includes those parts of the tibia, fibula, the malleoli and their related structures;
(iv)	Surgical treatment of the muscles and tendons at the level of the ankle joint and in the leg involving arthroplasty, osteotomy, grafts, implants and arthrodesis; and 
(v)	The administration of general anesthesia.
		Coverage DOES APPLY to injury arising out of any professional services covered in Limitation Provision One:
			1.	All podiatric surgical procedures performed on the human foot except those excluded above; and
			2.	Assisting in the performance of any podiatric surgical procedure.
	c.	Advanced Surgery   [    ] Yes [    ] No
Limitation Provision Three - Coverage DOES NOT APPLY (except in an emergency requiring immediate and unexpected intervention) to injury arising out of any professional service listed below:
(i)	The administration of general anesthesia.
Coverage DOES APPLY to injury arising out of all podiatric surgical procedures performed on the human foot and all of the services covered in Limitation Provisions One and Two.
	d.	(i)	Do you perform surgery in your office?	[   ] Yes  [   ] No
		(ii)	Do you perform surgery in a hospital?	[   ] Yes  [   ] No
		(iii)	Do you perform surgery in any other non-hospital facility?	[   ] Yes  [   ] No
		(iv)	Do you only perform non-surgical procedures or minor surgical procedures that are within
			the subcutaneous tissue only and that do not require sutures?	[   ] Yes  [   ] No
		(v)	Do you assist in surgical procedures outside the scope of podiatric medicine?	[   ] Yes  [   ] No
			(If Yes, please explain.)
		(vi)	Do you have a certificate to perform ankle surgery?  (If Yes, please attach copy.)	[   ] Yes  [   ] No
7.	PROFESSIONAL ORGANIZATIONS
	American Podiatric Medical Association	APMA	[   ] Yes  [   ] No
	American College of Foot Surgeons	ACFS	[   ] Yes  [   ] No
	Academy of Ambulatory Foot Surgeons	AAFS	[   ] Yes  [   ] No
8.	EDUCATION
	a.	List all the colleges and professional schools you attended:
		Name	Yrs. Attended	Date of Grad.	Degree

			
	b.	Post graduate education:
		(i)	Internship:    [   ] Yes   [   ] No
			Hospital: 	
			Location: 	
			(City)	(State)	(County)
			Dates of Training: 	
		(ii)	Residency/Fellowship/Preceptorship:   [    ] Yes [    ] No
			Hospital: 	
			Location: 	
			(City)	(State)	(County)
			Dates of Training: 	
		(iii)	Additional medical/specialty training:
			Type of Training	Dates
		_________________________________________________	______________
		_________________________________________________	______________
	c.	Board Certification: [    ] Yes   [    ] No
		If Yes, please indicate the name of the Board and the year certified: 	
9.	ADDITIONAL INFORMATION
	a.	Please attach three (3) of your most recent advertisements.
	b.	Please enclose copies of all your ads (e.g., Yellow Pages, etc.)
* NOTICE TO APPLICANT: The coverage applied for is SOLELY AS STATED IN THE POLICY, which provides coverage on a "CLAIMS MADE" basis for ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD unless the extended reporting period option is exercised in accordance with the terms of the policy.
WARRANTY: I/We warrant to the Insurer, that I understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Insurer evidence its acceptance of this application by issuance of a policy.  I/We authorize the release of claim information from any prior insurer to the underwriting manager, Company and/or affiliates thereof.

Name of Applicant		Title (Officer, partner, etc.)

Signature of Applicant		Date

SIGNING this application does not bind the Applicant or the Insurer or the Underwriting Manager to complete the insurance, but one copy of this application will be attached to the policy, if issued.