Cotizacion de Enfermeras

Seguros JCE valoran tenerle como uno de nuestros posibles clientes y agradecen su confianza y su patrocinio de nuestros productos y servicios. Seguros JCE respeta la privacidad de la información que nos comparten nuestros clientes y se compromete con éstos a mantener la confidencialidad y seguridad de la misma. JCE GROUP, INC no comparte ningún tipo de información de nuestros clientes o consumidores con personas no afiliadas, solo con aseguradoras según permitido por Ley.

Name of Insured

Father's Last Name

Mother's Last Name

Name

Initial

Social Security Number

Place of Birth

Date of Birth

Age

Citizenship

Home Address

Dirección Ciudad Estado / Provincia / Región ZIP / Código Postal

Home Telephone

Mailing Address

Dirección Ciudad Estado / Provincia / Región ZIP / Código Postal

Office Address

Dirección Ciudad Estado / Provincia / Región ZIP / Código Postal

Office Telephone

Coverage Period Desired

From

To

Limits of Liability

Each Medical Incident

Annual Aggregate

Number of Years at Current Employment

Previous Locations of Practice (indicate places and dates)

Professional School

Degree

Year

Address

Dirección Ciudad Estado / Provincia / Región ZIP / Código Postal País

Served Internship at

Year

Address

Dirección Ciudad Estado / Provincia / Región ZIP / Código Postal País

What is (are) your present specialty (ies)?

Are you registered and licensed to practice your profession in the commonwealth of Puerto Rico?

Yes
No

License Number

Date Issued

What is (are) your Sub-specialty (ies), (if any)?

Name Specialty Certifications which you hold

Name all hospitals which you have had or have staff membership or privileges and give nature of privileges at each and the dates during which those have been enjoyed

Indicate for which evidence of insurance is required?

In case of any "Yes" answer to any of the following questions, please explain details in the space provided below: indicating nature of action, date, country of state action took place, reasons for the same.

Has your license to practice your professional ever been refused, suspended, revoked or voluntarily surrendered in Puerto Rico or elsewhere?

Yes
No

Has your membership in any professional society or association ever been refused, suspended, revoked or voluntarily surrendered in Puerto Rico or elsewhere?

Yes
No

Has any hospital in Puerto Rico or elsewhere ever restricted, suspended or revoked your privileges or revoked probation?

Yes
No

Have you ever had any certification refused or revoked?

Yes
No

Do you plan to take additional residencies or change specialty within the next two years?

Yes
No

Do you work (full or part-time) in an emergency room or intensive care unit?

Yes
No

Explain

Are you employed or have you been in any capacity by any person or organization on salary or commission?

Yes
No

Name of group capacity in which employed, date.

Are of have you been active in U.S. Military Service?

Yes
No

Indicate position, where and dates.

Are you or have you been employed by the Federal Government (not active in U.S. Military Services)?

Yes
No

Indicate in what capacity, where and dates.

Are you partner, stockholder or member in a Medical Partnership, Association, Corporation or Joint Venture?

Yes
No

Name of Partnership

Association
Corporation
Joint Venture

List all members and specialty (ies):

Do you (or does your partnership / corporation / joint venture) employ any of the following:
Licensed Technicians

Radium

Yes
No

Laboratory

Yes
No

Pathological

Yes
No

X-Ray

Yes
No

Shock Therapy

Yes
No

Please indicate how many of each kind:

Are you affiliated in any supervisory or administrative capacity or do you have an ownership interest in:

Any Hospital, or Clinic with bed and board accommodations?

Yes
No

Any Clinic, Blood Bank, Laboratory or similar facility?

Yes
No

Full name and location of the facility as well as the specific name of the Department of Ancillary Service with which you are affiliated of official committee on which you serve:

Designate the exact capacity in which you serve (e.g. owner in whole or in part, executive officer, administrator, department or ancillary service or supervisor, physician with teaching responsibilities, etc.):

Indicate the number and specific profession classification or assistants (physician or non-physician employed by or rendering service for the above named facility who work under your supervision, direction or control or for whose acts you have assumed legal responsibility either by reason of your official appointment or under terms of any contract or agreement:

If you answer "Yes" to any of the following question please give details below:

Do you engage in any colleague group activities including but not limited to service as a member of a normal accreditation of similar professional board or committees, of a hospital or professional society, tissue committee, hospital credential committee of professional society peer committee?

Yes
No

Have you ever had your license refused, suspended or revoked?

Yes
No

If “Yes”, indicate or state, date and reason for said action.

Have you ever been treated and/or hospitalized for alcoholism, narcotics, addiction or mental illness?

Yes
No

If "Yes", indicate by whom, where and date.

Have you now, or had, any chronic illness or physical defect?

Yes
No

If "Yes", indicate nature

Have you ever been convicted of crime?

Yes
No

If "Yes, indicate nature, place, date, court case number and conviction.

Explain

Has any claim or suit for any alleged malpractice ever been brought against you?

Yes
No

If "Yes, indicate nature, place, date, court case number and conviction.

If "Yes" enclose copy of notice of intent to file claim, notice of extrajudicial claim and/or complaint for each and every case and a status report regarding each prepared by the insurance carrier providing coverage for said claim or by your defense counsel in said case indicating:
-loss indemnity paid by you on your behalf either per settlement or per judgment
-name of claimant, case number and court
-date of loss
-nature of alleged malpractice
-if case not resolved, stage of legal proceedings

Are you aware of any acts, errors, omissions, or circumstances which may result in a malpractice claim or suit which has not yet been brought against you?

Yes
No

Submit Details

Have you submitted to your last claims made malpractice insurer a list of any acts, errors, omissions or circumstances which may result in possible future malpractice claims or suits brought against you?

Yes
No

Provide a copy of said list

Indicate the date on which said list was submitted to your last claims made malpractice insurer:

Name of Insurer and Address

Have you ever had Professional Liability Insurance declined, cancelled, issued on special terms or renewal refused?

Yes
No

Indicate name of insurer, policy if applicable, date and reason for said action:

Please give name of your last insurer and policy number:

Type of coverage:

Occurrence
Claims Made

If claims made type of coverage please give number of years and/or months insured under the claims made program:

Number of years:

Number of months:

If claims made type of coverage, has it been continuously in force?

Yes
No

Please explain

Important Notice: “Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur in a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand ($5,000) dollars nor more than ten thousand ($10,000) dollars, or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years.”

I Accept

Aviso Anti Fraude:

Cualquier persona que a sabiendas y con la intención de defraudar presente información falsa en una solicitud de seguro o, que presentare, ayudare o hiciere presentar una reclamación fraudulenta para el pago de una perdida u otro beneficio o, presentare más de una reclamación por un mismo daño o perdida, incurriría en delito grave y convicto que fuere, será sancionado, por cada violación con pena de multa no menor de cinco mil ($5,000) dólares, ni mayor de diez mil ($10,000) dólares o pena de reclusión por termino fijo de tres (3) anos, o ambas penas. De mediar circunstancias atenuantes, podrá ser reducida hasta un mínimo de dos (2) anos. Artículo 27.320 de la ley #18 de 2004

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