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Application for Medical Facility and Enitity
Medical Facility and Entity Application for Legal Defense Insurance
Part 1: Identifying Information
Application Date
?
Requires a date stamp in the form of (dd/mm/yyyy)
Name of Facility
Name of Facility's Owning Entity
Principal Representing Owner: Last Name
Principal's First Name
Principal's Title
Facility Address
Telephone
Fax
Contact Email
Type of Facility
Facility Licence Number
License Expiration Date
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Requires a date stamp in the form of (dd/mm/yyyy)
Proceed to Section 2
Part 2: Occurrences
Please indicate your "Yes" or "No" response for each question below. If any answers to the following questions are "yes," please provide further information at the bottom of this section (please be sure to indicate which question you are providing information for in your response).
A. Has your Florida facility license been placed on probation, suspended, received a citation, denied, revoked or otherwise diminished by any local, state, federal, or country authority?
Response to Question A:
YES
NO
B. Are you currently being audited by or are you currently under investigation by Medicare Medicaid or Blue Shield program? (i.e., Probe Audit)
Response to Question B:
YES
NO
C. Have you been subject to notice of termination, or exclusion from status as a supplier of services under a Medicare, Medicaid or Blue Shield program?
Response to Question C:
YES
NO
D. Have you (or your insurance carrier on your behalf) settled any liability claims or potential claims against you? If yes, please provide supporting documents.
Response to Question D:
YES
NO
E. Are you in compliance with OSHA regulations?
Response to Question E:
YES
NO
F. What is your annual OSHA Compliance renewal date?
Renewal Date:
?
Requires a date stamp in the form of (dd/mm/yyyy)
G. Have you ever been cautioned, reprimanded, received a citation or otherwise been disciplined by OSHA?
Response to Question G:
YES
NO
H. Have you ever had to pay a penalty to any of the compliance programs?
Response to Question H:
YES
NO
If Yes, which regulator agency, amount and date paid?
I. Have you been audited by Medicare or Medicaid?
Response to Question I:
YES
NO
What was the date and finding of the audit?
J. Do you have office policies regarding your business and employee conduct?
Response to Question J:
YES
NO
K. Are you in compliance with the EEOC regulations (if applicable)?
Response to Question K:
YES
NO
L. Are you in compliance with federal immigration and homeland security regulations?
Response to Question L:
YES
NO
M. Do you currently have a Homeland Security Plan in effect?
Response to Question M:
YES
NO
N. Do you operate a drug-free workplace?
Response to Question N:
YES
NO
O. Agency for Health Care Administration (AHCA) questions: (Next Four Responses) What is the date of your last inspection?
Last Inspection Date:
?
Requires a date stamp in the form of (dd/mm/yyyy)
Where any deficiencies noted?
YES
NO
If yes, please provide ad explanation.
Does your entity have a transfer agreement? If no, please attach an explanation to this application.
Response:
YES
NO
P. Are your corporate records up-to-date and compliant with the minimum standards under Florida statutes? If no, please attach an explanation.
Response to Question P:
YES
NO
Proceed to Section 3
Part 4: Facility Liability Insurance Carrier
Company Name
Limits
Proceed to Section 4
Part 4: Declaration
I hereby declare and represent the above statements and particulars are true and complete, and I have not withheld or misstated any information requested by FPA LDIC, Inc. I understand and agree the information contained in this application is material, that FPA LDIC, Inc. is relying upon it in considering my application for legal defense insurance, and it is the basis of any policy of insurance which may be issued to me by FPA LDIC, Inc. I also understand this application shall be annexed to, and deemed a part of, any policy of insurance issued to me by FPA LDIC, Inc. I hereby authorize any person, company, insurer, hospital or other organization to release to FPA LDIC, Inc., any and all information, privileged or not, in their dominion, custody or control regarding insurance applications by me, professional liability insurance issued to me, claims made or suits brought against me, decisions, and notes of any credentials or disciplinary committees involving me, any employment or personnel records involving me, any records of training or experience involving me, and any health, medical, psychological or psychiatric records involving me, as well as any information obtained by any attorneys who are now representing or have in the past represented me. FPA LDIC, Inc., is authorized to make copies of this application and those copies shall be valid as originals.
Applicant Name
Applicant _Signature
Dated
?
Requires a date stamp in the form of (dd/mm/yyyy)
PLEASE CLICK "SUBMIT APPLICATION" AT THE BOTTOM OF THIS PAGE.
YOUR CURRICULUM VITAE AND FIRST YEAR PREMIUM MUST BE INCLUDED IN ORDER FOR YOUR APPLICATION TO BE PROCESSED; PLEASE MAIL TO: FPA Legal Defense Insurance Company 6817 Southpoint Parkway, Suite 1803 Jacksonville, Florida 32216-6299 Telephone: 904-854-6056 800-477-5709 Facsimile : 904-854-6057 Website: www.fpalegaldefense.com e-Mail: respond@fpalegaldefense.com "Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree." Florida Physicians Association Legal Defense Insurance Company, Inc. d/b/a FPA Legal Defense Insurance Company, FPA LDIC, Inc., Florida Professionals Association Legal Defense Insurance Company
BELOW IS FOR USE BY INSURANCE AGENTS ONLY
Submitting Agency
Submitting Agent
Agency Address
Agency Telephone
E-Mail
Facsimile
Date Submitted
?
Requires a date stamp in the form of (dd/mm/yyyy)
Please review your application very carefully before submitting.
Please verify you are human and enter the text you see in the box.
