Cotizacion de Malpractice de Doctores

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Seguros JCE
Cotizacion de Malpractice de Doctores

Cotizacion de Malpractice de Doctores

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*
First Name Middle Name Last Name
Date of Birth (mm/dd/yyyy)*
MM slash DD slash YYYY
Place of Birth
Gender*
- Male
- Female
Office Address*
Postal Address*
Office Phone
Cell Phone*
Office Fax*
Email*
INSURANCE HISTORY

Please provide the necessary information below with respect to your primary insurance coverage for the last three years, including the coverage in force as of the date of this application.
Primary Career Name
Policy Effective Dates
Policy Limits
Policy Number
Is your current policy premium surcharged?
- Yes
- No
Has any insurance company (including Lloyd’s of London) ever cancelled, declined to issue, refused to renew, surcharged your premium or issued coverage with any restrictions or exclusions?
- Yes
- No
Please explain fully
MEDICAL EDUCATION AND TRAINING
Medical School/Hospital Name
Medical School City/State/Country
Medical School City/State/Country
Medical School From/To
Medical School Degree/Type
Internship School/Hospital Name
Internship City/State/Country
Internship From/To
Internship Type
Residency School/Hospital Name
Residency City/State/Country
Residency From/To
Residency Degree/Type
If you are a graduate of a non-U.S. medical school, are you certified by the Educational Commission for Foreign Medical School Graduates?
- Yes
- No
Did you complete residency training?
- Yes
- No
SPECIALTY/BOARD CERTIFICATION
Primary Specialty
% of Practice
Secondary Specialty
% of Practice
Do you limit your practice to either the Primary or Secondary specialty?
- Yes
- No
Please explain
Are you Board Certified in one or more areas?
- Yes
- No
MILITARY
Are you currently active in Military Service
- Yes
- No
Type of discharge
LICENSES AND AFFILIATIONS

Specify states or countries where you are or have been licensed
License 1 State / Country
License 1 Year
License
License 1 Status
License 2 State / Country
License 2 Year
License
License 2 Status
Are you a member of any national medical societies? (Not Specialty)
- Yes
- No
Please list
Are you a member of any national specialty societies?
- Yes
- No
Please list
Are you a member of any state medical society?
- Yes
- No
Are you a member of your local medical society?
- Yes
- No
HOSPITAL AND FACILITY CENTER PRIVILEGES

List all Hospitals and/or other surgical centers or facilities where you currently have privileges or applications for privileges pending. Indicate privileges and restrictions, if any.
Hospital/Facility 1
City
Privileges
Restrictions
Hospital/Facility 1
City
Privileges
Restrictions
CURRENT PRACTICE LOCATIONS

List all offices where you currently practice..
Address/Suite City Country
Address/Suite City Country
Where have you practiced your profession since completion of your formal training? (Include military or any public service organization). PLEASE ACCOUNT FOR ALL TIMES SINCE COMPLETION OF YOUR MEDICAL SCHOOL, WITH THE EXCEPTION OF YOUR RESIDENCY OR FELLOWSHIP TRAINING. INCLUDE YOUR SPECIALTY AT THAT TIME.
Entity Name
Dates
Address
Speciality
Entity Name
Dates
Address
Speciality
Check the boxes that best describe the type of practice you currently have
- Solo Physician
- Partnership
- Professional Association
- Other
- Employed physician
- Group Member
- Professional Corporation
Entity Name
Title (partner, shareholder, employee, contractor)
Name of partners, shareholders, employers
If you have or are applying for excess coverage, do all members of your night, weekend, vacation or illness “on-call” referral group carry excess professional liability?
- Yes
- No
If you or your Medical Partnership/Corporation employs any health care professionals, please indicate the employee’s name, specialty, insurance carrier and limits of liability below.
Name
Speciality
Insured By
Limit of Liability
Do you perform any of the following: drainage of an abscess, tissue biopsies, incising of boils and superficial fascia, suturing or minor lacerations, removal of superficial skin lesions by other than surgical excision?
- Yes
- No
Do you obtain a dully signed informed consent form from every patient prior to each surgery?
- Yes
- No
Which consent do you use?
- Your own consent form
- A hospital’s preprinted form
Provide a general description of your activities for which other professional liability coverage is provided and will not be covered by PRMD
Please check any of the following procedures that you perform and provide estimates of how many you perform each year
- Angioplasty
- Angioplasty (PTA)
- Arteriography
- Biopsy
- Breast
- Breast Implants
- Cardiac Catheterization
- Coronary Angiography
- Cholangiography
- Contrast Media CNS
- Endoscopic Sclerotherapy
- Hexagonal Keratotomy
- Intraocular Lens Implants
- Intragastric balloon placement
- VPs
- Kidney
- Liver
- Liposuction
- Lung
- Myelography
- Temporary Pacemaker Insertions
- Permanent Pacemaker Insertions
- Percutaneous Transhepatic
- Percutaneous Gastrostomy
- Periocular tattooing
- Prostate
- Radiation Therapy (other than grenz ray)
- Robotic Surgery
- Silicone
- Saline
- Therapeutic use of radioactive materials
- Use of laetrile
- Use of chelation therapy in treatment of cardiovascular disease
Do you perform surgical procedures?
- Yes
- No
Procedure 1
No. Performed Per Year
Percentage of Practice/Year
Procedure 2
No. Performed Per Year
Percentage of Practice/Year
Do you practice/work shifts in an Emergency Room or a Treatment and Diagnostic Center “CDT”?
- Yes
- No
Do you anticipate your surgical practice will change significantly in the coming year?
- Yes
- No
Please explain
Do you perform major surgery in a freestanding facility or in your own office?
- Yes
- No
Are you entering practice for the first time since completing an internship, residency, fellowship or military service?
- Yes
- No
Has your practice specialty/procedures changed in the last 5 years?
- Yes
- No
Please explain
If you are a radiologist, ophthalmologist or dermatologist do you practice Laser Surgery?
- Yes
- No
If you are a Radiologist or Pathologist, do you read, interpret or diagnose films, slides or specimens taken of patient who resides outside of Puerto Rico?
- Yes
- No
Please explain
If you are an Orthopedic Surgeon do you practice
- Spine Surgery
- No Spine Surgery
Do you practice obstetrics including prenatal care?
- Yes
- No
If you are a Gynecology Surgeon, who practiced Obstetrics; when did you perform your last delivery?
Do you perform sex-reassignment surgery?
- Yes
- No
Do you perform weight control surgery?
- Yes
- No
STAFF PRIVILEGES/MANAGED CARE ORGANIZATION ACTIONS OR INVESTIGATIONS
Have you ever had any hospital or surgical outpatient privileges denied, suspended, revoked, restricted, reduced, not renewed, proctored or modified in any way?
- Yes
- No
Have you ever been investigated by any entity which as its principal activity is a health care service plan, third party administrator, or other business or organization arranging for the provision of health services, or by any entity or organization providing or responsible for the provision of health care services, including any medical corporation, independent practice association, preferred provider organization, physician panel, or other entity or arrangement entering into agreements with third party payers for the provision of medical care, for the purpose of disciplining you or limiting, revoking or suspending your continued exercise, maintenance or renewal right or entitlement to provide medical or surgical care to persons receiving health care arranged or rendered by such entity or organization?
- Yes
- No
GOVERNMENTAL ACTION
Have you ever been investigated as the subject of, charged with or convicted of a misdemeanor or felony?
- Yes
- No
Have you ever entered a “no contest” plea to a crime, other than a traffic violation?
- Yes
- No
Have you ever been investigated by any state or federal regulatory or specialty society?
- Yes
- No
Has any governmental agency ever suspended, revoked, restricted, placed you on probation, or taken any other action against your medical or narcotics license?
- Yes
- No
HEALTH
Have you EVER been evaluated, recommended for treatment, diagnosed with, or treated for alcohol, narcotics or any other substance abuse, sexual addiction or mental illness?
- Yes
- No
Are you being treated for any medical condition, disease or illnesses that affect your ability to practice medicine?
- Yes
- No
Do you have any physical handicap or any chronic illness?
- Yes
- No
Have you EVER been accused of sexual misconduct of any kind?
- Yes
- No
CLAIM HISTORY
Have you EVER been involved in a malpractice claim or suit, either directly or indirectly?
- Yes
- No
Are you aware of any of the following circumstances (not included as an answer to events on question 53) that might reasonably lead to a claim or suit being brought against you, even if you believe the claim or suit would be without merit,
A request for records from a patient and/or attorney related to an adverse outcome?
- Yes
- No
A letter from an attorney regarding your medical treatment of a patient?
- Yes
- No
Intra-operative or post-operative complications or other complications resulting in death, paralysis, or other significant disabilities?
- Yes
- No
Patient or family member dissatisfaction with the outcome of a procedure, treatment, or diagnosis?
- Yes
- No
Any other circumstances that might reasonably lead to a claim or suit?
- Yes
- No
If you answer “Yes” to any of the items, have these circumstances been reported to your current or professional liability carrier?
- Yes
- No
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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