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Application for Physicians, Doctors, Dentists
Part 1: Identifying Information
Application Date
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Requires a date stamp in the form of (dd/mm/yyyy)
Applicant's Last Name
Applicant's First and Middle name
Applicant's Date of Birth
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Requires a date stamp in the form of (dd/mm/yyyy)
Mailing Address
Telephone
Fax
Contact Email
Medical Specialty
Florida Medical License Number
Medical License Expiration Date
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Requires a date stamp in the form of (dd/mm/yyyy)
Drug Enforcement License Number
Drug Enforcement License Expiration Date
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Requires a date stamp in the form of (dd/mm/yyyy)
Proceed to Section 2
Part 2: Hospital Affiliations (If applicable)
List all present hospital/professional affiliations and Medical Staff appointments in chronological order, beginning with the most recent dates (include assistantships and teaching appointments). If necessary, please contact us to arrange sending additional pages/information.
Hospital Affiliation 1
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Please list the name of the hospital/affiliations, your staff status, beginning and ending dates for each affiliation.
Hospital Affiliation 2
Hospital Affiliation 3
Proceed to section 3
Part 3: 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 professional 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. Have your staff privileges at any facility been placed on probation, denied, revoked, restricted, or suspended for any reasons other than incomplete medical records?
Response to Question B:
YES
NO
C. Has your appointment to the Medical Staff of any facility or your membership in any local, state or national professional society been denied, placed on probation, suspended, revoked, restricted or otherwise diminished?
Response to Question C:
YES
NO
D. Have you withdrawn your application for appointment to the medical staff of any institution?
Response to Question D:
YES
NO
Have you resigned your appointment to the medical staff of any institution?
Response to Question E:
YES
NO
F. Has your registration to dispense controlled substances been denied, placed on probation, suspended, revoked, or otherwise diminished?
Response to Question F:
YES
NO
G. 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 G:
YES
NO
H. 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 H:
YES
NO
I. Have you been charged with a criminal offense (other than minor traffic violations)?
Response to Question I:
YES
NO
J. Have you (or your insurance carrier on your behalf) settled any medical liability claims or potential claims against you? IF YES, PLEASE PROVIDE SUPPORTING DOCUMENTS.
Response to Question J:
YES
NO
K. Have you ever been cautioned, reprimanded, received a citation or otherwise been disciplined by OSHA?
Response to Question K:
YES
NO
L. Have you ever been charged, criminally or civilly, with any action related to the use or misuse of drugs, alcohol or chemical substances?
Response to Question L:
YES
NO
M. Have you ever had to pay a penalty to any of the compliance programs?
Response to Question M:
YES
NO
If "Yes," list which regulatory agency, amount and date paid.
N. Have you been audited by Medicare or Medicaid?
Response to Question N:
YES
NO
If "Yes," what was the date and finding of the audit?
O. Do you have any known losses, claims or potentially compensable events that have not been reported to your prior insurance carrier?
Response to Question O:
YES
NO
P. Do you have any known information relating to a medical incident which could reasonably result in a claim, and/or complaint against your medical license?
Response to Question P:
YES
NO
Q. Do you have any knowledge of any request for medical records which might result in a claim?
Response to Question Q:
YES
NO
R. Has any prior professional liability carrier refused coverage for, or declined to accept a report of a medical incident, threat of claim, letter of intent, adverse result notice or attorney contact?
Response to Question R:
YES
NO
S. All the above information has been answered accurately and is true from the date of issuance of my medical license to the date of signing this application.
Response to Question S:
YES
NO
Proceed to Section 4
Part 4: Professional Liability Insurance Carrier
Company Name
Limits
IF NO MALPRACTICE COMPANY LISTED ABOVE, COMPLETE THE FOLLOWING: I hereby acknowledge and attest that as a condition of my license to practice medicine in the State of Florida, I have demonstrated to the satisfaction of the Board and the Department financial responsibility to pay claims and costs ancillary thereto arising out of the rendering of, or the failure to render, medical care or services as outlined in Florida Statute ยง458.320.
I have complied with these requirements by:
Applicant Signature
Dated
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Requires a date stamp in the form of (dd/mm/yyyy)
Proceed to Section 5
Part 5: Declaration
I hereby declare and represent the above statements and particulars are true and complete from the date of insurance of my medical license to the date of this application, and that 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
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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
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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.
