EFTA00311431.pdf

CNA The Professional Protector Plan® hot PettetotPlat *DWI* Property Supplement Name: (First/Middle InitiaVLast/Designallon) Policy Number Desired Effective Date PROPERTY INFORMATION (Please complete a separate property supplement for each practice location. 1. Practice Th ss: OS V -1--. 009Da Street City County State Zip Code 2. DescrIbe the building in which you we located Construction Floor on Total Sq. Square Square Anent Use of Building No. of Which You Year Footage of Footage of Footage of Basement(s) 9filt you occupy Stories Are Located Built Building Your Office Basement(s) Finished Protection Class 1. -1. a2oac lao0 320 070V Winos C8/0&./4 3. Year building updated Of over 25 years of age) . Year Roof Updated Electric Meets Building Codes Yes No Plumbing is maintained to prevent exposure to leaking or frozen pipes Yes No Building was built for a different occupancy and has been modified Yes No If Yes, please describe: 4. Is your practice location equipped with any of the following systems? YES NO V„. Central Station a. Sprinkler 0 0 b. Fire alarm . .. NAY' 0 0 c. Smoke detectors L•rir 0 0 d. Burglar alarm ... 0 0 1.0---- 5. Is your practice located in your residence? ilKes 0 No If *Yes; does your office have a separate entrance? 'Lines 0 No 6. What is your practice location's distance to the nearest fire station? ...5— sties 7. Do you utilize a watchman service? . Ores 0 No 8. Are cash and checks deposited daily?... .. 0 Yes ido 9. How do you store your cash on hand, prescription drugs, precious metals? I 04fife 0 Fire Resistive Container 0 Other (describe) a. Amount of cash left on premises overnight .. $ SOOV b. Value of drugs $ dinoto c. Value of metals .. $ ...5'0 1 -— d. Value of other (describe) $ /Via 10. How do you store your accounts receivable records? LaM 11. Do you maintain duplicate accounts receivable records? .. ties 0 No 12. Are accounts receivable duplicates kept off your premises? .. ':0 Yes 0 No G-151513.1) (Ed. 0512006) EFTA00311431 DESCRIPTION OF CONTENTS 13. Are you within 1 mile of an ocean, gulf or river? NyceS 8 No 14. Are you less than 10 feet above sea level? . .0 Yes t9.416 15, Total number of operatories: Fully equipped: '1 Partialy equipped: Bays: 18. Name and address of Loss Payee or Lessor on contents (i.e., office and dental equipment): ett_inn....0., Name L3 3 - Devi ret L Lc Street City State Zip Code btu Roy( PkOli6164-kt B3 u-7 096 )01 Name Street State Zip Code 17. Which coverage do you prefer? kl , PP Standard 0 PPP Gold (Please contact your agent for information on this valuable coverage) Estimate the total cost to replace Dental Practice Personal Property: PPP Standard Amount o( A. Practice Contents: #2.coop .... Coverage Desired 1. Furniture and fixtures + 2. Operatory equipment + 3. Instruments and supplies + 4. Improvements and betterments • 5. Glass ... + 6. Other + Practice Contents Subtotal (100% Replacement cost) $r' or-, -0 - B. Practice Records/Charts. Account Receivables, valuable Papers, X-Rays: $25,000 minimum + 475,000 C. Dental Practice Blanket Limit Total (A + B) + D. Signs not attached to bulking . $10,000 • if) °op 18. Inflation Guard — Dental Practice Personal Property Optional . 9L (May select quarterly increase from 1% - 5%) Quarterly 19. Valued Practice Income $ / Minimum daily limit of $300 / 32.5 days Daily Limit 1# days 20. Employee Dishonesty: a. money/securities $10,000 $ i.),604) b. welfare and pension plans $15,000 S—/5-..c",5 .7 -- 21. Rents (annual rental income) Optional $ 22. Dentist's Electronic Equipment (including Electronic Data Processing equipment) $25,000 $ 0.75;tooD Do you use surge protection devices? B Yes 0 No 23. Equipment Breakdown Coverage? 0 Yes 0 No $ 0 Dental Equipment only $ 6 Dental Equipment and Heating,Ventilation 8 Air Conditioning Equipment Do you own the building in which your office is located? 0 Yes 0 No 24. Fine Arts (attach appraisals, if additional coverage Is desired) .510,000 subject to maximum 31,000 per item $ 25. Have you had any coverage defined or property losses (fire, burglary, water damage, premises, earthquake, etc.) or employee dishonesty tosses during the past three (3) years? . 0 Yes 0 No if 'Yes', please give details (cause of loss, amount paid, date of loss) on a separate sheet of paper. 26. Property Deductible - $250 (Optional Deductibles of $500. $1,000, $2,500, $5,000 and $10,000 available (Please contact your agent) $ 67, 5.-CO G-151513-D (14. 05:20(1) 2 EFTA00311432 BUILDING INFORMATION - Complete only if you desire insurance on the building through this plan 27. Building — (Current Cost to Replace) $ a. additional buidings on premises (garage, storage building) $ b. inflation guard (may select quarterly increase from 1% - 5%) .. Mandatory % Quarterly 28. Please indicate % of vacancy, or tenants by type of business and/or operations conducted, and square footage for each Sq. feet: Sq. feet 29. Is your buiding located on a known land subsidence area? ...0 Yes ArNo 30. Is your building resting on a saturated man-made (filled ground) or alluvial (soft) soil? ...0 Yes )'No 31. Name of building owner. L-5.J t L L(L, 32. Name and address of Mortgagee: Hig" Name Street City State Zip Code Name Street City State Zip Code 33. Descnbe the occupant to the right of Descnbe the occupant to the left of your Describe the occupant to the rear of your your building, Including distance. building, including distance. building. including distance. 1‘11A N/ t1 N)4 I hereby acknowledge that the aforementioned statements and answers are correct and complete. I further understand that any incorrect or incomplete statement could void my protection. I hereby authorize the CNA Insurance Companies to release the information on this application and associated underwriting information. FRAUD NOTICE — WHERE APPLICABLE UNDER THE LAW OF YOUR STATE 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 or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which Is a crime AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES (for New York residents only: and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.) (For Pennsylvania Residents only: Any person who knowingly and with intent to Injure or defraud any insurer files an application or claim containing any false, Incomplete or misleading Information shall, upon conviction, be subject to imprisonment for up to seven year and payment of a fine of up to $15,000.) (For Tennessee Residents only: Penalties include imprisonment, fines and denial of insurance benefits.) /044/29,4r Signature in full: Date G-1515B-1) (Ed. 05.20(16) 3 EFTA00311433  CIA The Professional Protector Plan® haterend The Claims-Made pfcbcb:s frr Professional Liability Insurance For Dentists THIS IS AN APPLICATION FOR CLAIMS MADE COVERAGE WHICH, SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO ANY CLAIM FIRST MADE AGAINST THE INSUREDS DURING THE POLICY PERIOD. NO COVERAGE EXISTS FOR CLAIMS FIRST MADE AFTER THE END OF THE POLICY PERIOD, UNLESS, AND TO THE EXTENT, AN EXTENDED REPORTING PERIOD APPLIES I Please answer all questions. Do not leave any blanks. If a question is not applicable, please write N/A. 2. Application must be signed and dated by applicant 3 A copy of your letterhead must be included. Also, please Include a copy of all of your 'Yellow Pages' advertising, if any. I agree that any coverage issued will be contingent upon the truth of the following information: LIMITS REQUESTED: New Policy Requested Effective Date: 0 / 47-6/20,6" O $1,00%000 / 33,000,000 O $3,000,000 / $6,000,000 O $2 000,000 / $3,000,000 CI $4,000,000 / $4,000,000 O Rewrite of PoliaNumber O $2,000,000 / 54.000,000 CI $5,000,000 / $5,000,000 U $3.000,000 / $3,000,000 la $5.000.000I $8.000.000 U Other. $ is Website: (STATE EXCEPTIONS: IN, FL, KS, PR, NY, SC, VA) PLEASE TELL US ABOUT YOURSELF I. Name: (First/Middle Initial/Last/DesignatiorTEThs U omo 2. Social Security Number 3. Date of Birth: O mo CI aos ifrit ythq Shaliii 4( 4. Ma)'ling Addr L.7/ t9C) C( ( 100 614/42/(17 6-$ i/ 71€2fil•tS vs vr OUSE Street City Stale Zip Code 5.igi viaj hr n r oim 6. Fax Number: 7. E-mail Address (_.—) 8. Years! Practice: 9. Dental School Attended: 10. Month/Year of Graduation: (0/imbh O4O1449 Scipio/ hit 20 /5- 11. Are you entering practice for the first time? tdYes UNo if *Yes, did you complete a residency? .. °Yes largo Specialty: Month/Year of Completion: 12. Business structure under which you practice (Check all that apply): A. O Employee O Independent contractor O Sole proprietor O Incorporated 0 Partnership a L. L. C. O L. L. P. O Professional Association O Professional Corporation O Other (describe) Provide the name of the Legal Entity / S. Owied l -L C- • Do you desire shared or separate limit of liability to apply to this entity? a Shared (limits are shared with you) O Separate (entity has its own set of limits) B. Besides yourself, list the names of all dentists who are partners/corporate officers for all legal entities: pi additional space is needed, please list on a separate sheet of paper). (Note: All partners/ corporate officers must be Insured by CNA) Name Social Security No. Name Social Seemly No. Name Social Security No. Name Social Security No Name Social Security No. Name Social Security No. C. If you own your practice, please provide the number of the following who work for you: 0 of full-time # of pan-time Employee dentists (other than yourself and/or partners/corporate officers)? (Attach separate application or proof of professional liability Insurance) Independent Contractor dentists . (Attach separate application or proof of professional katAity insurance) All other employees (i.e., hygienist, dental assistants, technicians. etc.) . Total U C) G-19547-F (Ed. 05/06) EFTA00311434  D. Do you work for another dentist as an independent contractor dentist? °Yes .?No if "Yes", please provide the name of the employer/facility. E. Do you work for another dentist as an employee dentist? OYes,12(No If "Yes", please provide the name of the employer/facility: F. Do you share dental facilities with other dentists who are not covered under this policy? OYesA1No If "Yes", attach proof of professional liability insurance for the other dentists 13. Practice Addresses and Percentage of Practice at Each Address (Total of Percentages Must Equal 100%): Primary 1) Street City County State Zip Code % 2) Street City County State Zip Code % 3) Street City County State Zip Code % 14. Are you a member of your state dental association or society? °Yes ONo 15. How many hours per week do you practice (include lab work, patient visitation and consultation)? in If 20 hours or less, please complete a Part-time Supplement 16. Are you currently licensed to practice dentistry? LlYes ONo State(s): License #(s): 17. Have you taken one of the following risk management seminars in the last 3 years? OYes ONo O CNA (Evidence not required if you are a CNA insured) O Hartford O MOMS O MO O Princeton O NYSDA Date of Attendance / / If Wes", provide evidence of attendance. 18. Indicate your Practice Specialty k‘General Dentistry O Periodontics O Endodontics O Oral Radiology O Prosthodontics O Oral/Maxillofacial Surgery O Orthodontics O Public Health O Oral Pathology O Pediatric Dentistry O Full-time Faculty-Non-Intramural O Anesthesiology(Dental)-Conscious Sedation O Anesthesiology(Dental)-General Anesthesia 19. Which of the following procedures are performed by you: O Irreversible TMJ-Phase II (such as bridgework, surgery, orthodontics undertaken primarily to treat a TIV1J disorder) O Implant Surgery O -Sargentr. paste fill or similar endodontic techniques %Extraction of Impacted teeth O Implant Restoration O Molar Endodontics on Permanent Teeth O Sleep Apnea Therapy If "Yes", please indicate the foNowing: O I treat only after referral from physician O I treat without physician referral O I fabricate snore guard 0 Weight Lou Therapy, Including DOS System If "Yes", please indicate the following: O I treat only after referral from physician O I treat without physician referral DDS System Certification Date: O Cosmetic dermal procedures (Including Botox, restInor hyaluronic acid products, collagen injections, dennabraalons, etc.) If "Yes", please provide an explanation on a separate sheet of paper. O Consulting Services (Rendering advice or recommendations, practice management consulting, expert witness testimony) If "Yes", do you desire coverage? O Yes 0 No O None 20. A. Have you ever had a change in the status of your hospital privileges? O Yes at No If 'Yes', provide details on a separate sheet of paper. B. Has any governmental agency, including a state licensing board, ever taken action against either your dental an:gar narcotics license including suspension, revocation, probation, restriction, denial or other sanctions? O YesZ No If *Yes", provide a copy of the board transcript or other documentation, including resolution. C. Have you been under investigation or currently under investigation by any governmental agency including a state licensing board or other regulatory agency? O Yes.tfNo If 'Yes", provide a copy of the board transcript or other documentation, inducing resolution. D. Have you been convicted of any criminal charges? O Yes? No If 'Yes", provide detags from Investigating agency. E. Have you ever been treated for alcoholism, drug addiction, mental illness or physical impairment? O Yes ti-No If 'Yes', provide a letter from treating physician with complete details. G-19547-F (Ed. 05/06) 2 EFTA00311435 PLEASE TELL US ABOUT YOUR USE OF ANESTHETICS AND ANALGESIA Please be sure to read and answer all parts very carefully. For purposes of these questions, the following definitions of Anxiety Reduction, Conscious Sedation and General Anesthesia/Deep Sedation are provided: • Anxiety Reduction is defined as `the use of nitrous oxide/oxygen and/or oral premedication used in an accepted therapeutic dose to reduce anxiety? • Conscious sedation is defined as: 'A minimally depressed level of consciousness that retains the patient's abity to independently and continuously maintain en airway and respond appropriately to physical stimulation and verbal command, produced by a pharrnecotogic or non•pharmacologic method. or a combination thereof? • General Anesthesia and Deep Sedation are defined as: 'A controlled stale of depressed consciousness or unconsciousness, accompanied by partial or complete loss of protective reflexes, Including inabilly to independently maintain an airway and respond purposely to physical stimulation or verbal command, produced by a phermacologic or non•pharmacologlc method, or a combination thereof.' 21. A. Is your practice limited to the use of local anesthesia, oral medication and/or nitrous oxide? trifles ❑ No 6. Are you treating patients who are under conscious sedation? Yes O No C. Are you treating patients who are under general anesthesia / deep sedation?.. O Yea' No If "Yes", where are the procedures performed? .. O In your office ❑ In a hospital or surgical center If "In Your Office", who administers the anesthesia? . O You CI Another Dentist, Anesthesiologist or CRNA PLEASE TELL US ABOUT YOUR INSURANCE HISTORY Do not complete questions 22 through 29 if you are a current PPP insured. 22. Are you now, or have you ever, practiced without professional liability insurance? ❑ Yes O No If "Yes', provide dates and reason: 23. Have you ever had any professional liability insurance refused, cancelled or non-renewed? U Yes O No If "Yes", provide dates and reason: (NOT APPLICABLE FOR MO) 24. Has any claim or suit for alleged malpractice ever been brought against you? O Yes :I No If -Yes", please complete Supplemental Claim form. 25. Are you currently aware of any situation that could lead to a malpractice suit against you? O Yes O No If "Yes", please complete Supplemental Claim form. 26. List prior carrier(s) for the past three (3) years. If none, state "None? Insurer Effective Expiration Claims-made or Limits of Date Date Occurrence Liablity 27. Are you applying for prior acts coverage from CNA? O Yes U No If 'Yes", please attach a copy of your last declaration page (face sheet). 28. Prior Acts date (Retroactive date) used by your previous carrier 29. Was an extended reporting endorsement (tail) purchased form your previous carrier? U Yes LJ No G-19547-F (Ed. 05/06) 3 EFTA00311436 PLEASE TELL US ABOUT YOUR PREMISES/OPERATIONS 30. If your equipment lease or rental requires you to name the equipment lessor as an additional insured, Arm please provide the name and address of the lessor as it appears on the lease or rental agreement: — E / LC MO lac( 16(O0ff QvaAkf _3 ) k- omis v -L- coaPol (- 31. I your building lease requires the building owner to be included as an additional insured for the portion of the ;premisesleased to you, please list the Lessor's name and address as it appears on your lease: k 32. Have you had any general liability losses in the past three (3) years? ..O YesliNo If "Yes", provide date(s) of loss and detail(s). 33. Do you want ERISA Fiduciary Liability coverage (5100,000 Limit of Liability)? ..CI Yesgl No Coverage is recommended if you sponsor any Employee Benefit Plan. Coverage is written on a Claims-made basis. I hereby acknowledge that the aforementioned statements and answers are correct and complete. I further understand that any Incorrect or incomplete statement could void my protection. I hereby authorize the CNA Insurance Companies to release the information on this application and associated underwriting information. I understand that my Professional Liability Coverage will be written on a 'Claims-Made form' and acknowledge that this coverage will only respond to claims which are reported during the term of this policy. I also acknowledge that my "Claims-Made" coverage will not provide insurance coverage for claims which occurred prior to the "Prior Ads Date" of my policy. I understand that, should my "Claims-Made" policy with this insurance carder ever be canceled or non-renewed, or I decide to terminate it for any other reasons, and I desire to provide insurance protection for any claims which may have occurred during the term of the "Claims- Made" policy, but were not reported to the insurance company before the date of the policy termination, I will be able to purchase additional insurance coverage. FRAUD NOTICE — WHERE APPLICABLE UNDER THE LAW OF YOUR STATE Any person who knowingly and with intent to defraud any instance company or other person files an application for insurance or statement of claim containing any materially false or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance ad, which is a crime AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES (for New York residents only and shall also be subject to a civil penalty not to exceed five thousand dollars and the staled value of the claim for each such violation.) (For Pennsylvania Residents only Any person who knowingly and with intent to injure or defraud any insurer ries an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven year and payment of a fine of up to 515,000.) (For Tennessee Residents only. Penalties include imprisonment, fines and denial of insurance benefits.) COMPLETION OF THIS FORM NEITHER BINDS COVERAGE NOR GUARANTEES A POLICY WILL BE ISSUED. ia l e2Lido Signature in full: Date G-19547-F (Ed. 05/06) 4 EFTA00311437  REMINDER: Please attach a sample of your letterhead and a copy of all of your dental practice "Yellow Pages" advertising, if any, to this application. RETURN TO: State Administrator Name: Address: City: State: Zip Code: Phone #: ( ) Agents License Number: The Professional Protector Plan® is a registered trademark of Brown & Brown, Inc.®. Coverage is underwritten by Continental Casualty Company, one of the CNA property/casualty insurance companies. CNA is a service mark registered with the US Pater and Trademark Office. G-19547-F (Ed. 05106) 5 EFTA00311438