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)*

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 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 Ciudad País

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

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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