Safeshield - Medical Professional Liability Application

Serving CT, NY, NJ, PA, DE☎ (203) 204-2555 | info@gosafeshield.com

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Safeshield - Medical Professional Liability Application

Complete the form below so we can shop 73+ carriers for the right coverage at the best price.

★★★★★

"Austin got us our GL, workers comp, and commercial auto placed in one week. Nobody else came close."

— Tony M., Electrical — Stamford CT

★★★★★

"Eric got our COI to the GC in 20 minutes. We've never had an agency turn certs around that fast."

— Danny R., Plumbing — Norwalk CT

★★★★★

"Switched our whole construction book. Austin found better coverage and saved us $14K annually."

— Marco S., General Contractor — Bridgeport CT

★★★★★

"Justin helped us get a last-minute COI for a job in Manhattan. Friday at 4pm. Had it before 5."

— Chris P., HVAC — Bronx NY

★★★★★

"We're a landscaping company with 12 trucks. Austin understood our exposures — inland marine, hired/non-owned, all of it."

— Ray L., Landscaping — Greenwich CT

★★★★★

"After 15 years with State Farm I finally switched. Better coverage for less money in one phone call."

— Kevin O., Homeowner — Stamford CT

★★★★★

"They set up our entire commercial package and had certs to our three biggest clients within 24 hours."

— Sam K., Roofing — Danbury CT

★★★★★

"Eric rewrote our workers comp and saved us $8K. First agent who ever explained class codes straight."

— Pete D., Masonry — Waterbury CT

★★★★★

"Austin got us our GL, workers comp, and commercial auto placed in one week. Nobody else came close."

— Tony M., Electrical — Stamford CT

★★★★★

"Eric got our COI to the GC in 20 minutes. We've never had an agency turn certs around that fast."

— Danny R., Plumbing — Norwalk CT

★★★★★

"Switched our whole construction book. Austin found better coverage and saved us $14K annually."

— Marco S., General Contractor — Bridgeport CT

★★★★★

"Justin helped us get a last-minute COI for a job in Manhattan. Friday at 4pm. Had it before 5."

— Chris P., HVAC — Bronx NY

★★★★★

"We're a landscaping company with 12 trucks. Austin understood our exposures — inland marine, hired/non-owned, all of it."

— Ray L., Landscaping — Greenwich CT

★★★★★

"After 15 years with State Farm I finally switched. Better coverage for less money in one phone call."

— Kevin O., Homeowner — Stamford CT

★★★★★

"They set up our entire commercial package and had certs to our three biggest clients within 24 hours."

— Sam K., Roofing — Danbury CT

★★★★★

"Eric rewrote our workers comp and saved us $8K. First agent who ever explained class codes straight."

— Pete D., Masonry — Waterbury CT

General Applicant Information

Basic information about you and your practice

Name of Applicant *

Professional Degree *

Principal Practice Address *

Secondary Practice Locations (if any)

Phone Number *

Website

Email Address *

Date of Birth *

Place of Birth

Social Security Number *

Federal Tax ID Number

Are you a U.S. citizen? *

Yes No

If No, what is your status in the U.S. and current citizenship?

Practice Structure & Type

How your practice is organized

Type of Practice *

Solo Practitioner (unincorporated) Professional Corporation Professional Association Limited Liability Company Partnership Employee Independent Contractor Other

If incorporated/partnership/LLC, specify name of entity

Do you want coverage for the entity named above?

Yes No

Do you practice with any physician not employed by your entity?

Yes No

If Yes, provide the name of each physician and the practice relationship

Are you currently in active military service?

Yes No

Licensing & Hospital Privileges

All states where you practice and hospital affiliations

List ALL states where you are licensed *

Federal DEA License Number and Status

List ALL hospitals where you have privileges

Are you currently a hospital chief of staff or head of any hospital department?

Yes No

If Yes, describe your leadership role

Do you own, operate or administer any hospital, nursing home, surgicenter, urgent care center or other medical facility?

Yes No

If Yes, provide detailed explanation including name, location, size, and number of beds

Is the Applicant a 'Covered Entity' under HIPAA Privacy Rule?

Yes No

If Yes, have you implemented procedures to comply with HIPAA Privacy Rule?

Yes No

Name and title of your Privacy Officer

Education & Training

Medical school, residency, fellowship, and board certification

Your medical specialty *

Do you limit your practice to the specialty stated above?

Yes No

If No, provide details of other areas you practice

Are you board certified in any specialty?

Yes No

If Yes, list all board certifications with dates

Medical School - Name and Location *

Medical School Graduation Date *

Internship - Institution, Location, Specialty, Dates

Residency - Institution, Location, Specialty, Dates

Fellowship - Institution, Location, Specialty, Dates

Other Training - Institution, Location, Specialty, Dates

If you graduated from a foreign medical school, provide the date you began practice in the United States

Detailed summary of where you have practiced since completing training *

Professional Organizations (check all that apply)

American Medical Association American College of Physicians American Academy of Family Physicians American College of Surgeons Specialty Medical Society State Medical Society Other

If Other, please specify

How many hours of continuing medical education have you taken within each of the last two (2) years?

Scope of Practice

Detailed breakdown of your medical practice areas

Provide the approximate percentage of your practice in each area you practice *

Do you use experimental procedures, devices, drugs or therapy?

Yes No

If Yes, do you follow FDA-approved protocols?

Yes No

If Yes, describe the experimental procedures/devices/drugs

Are you a Principal Investigator for any clinical trial?

Yes No

Has the nature of your practice or procedures changed in the last 5 years?

Yes No

If Yes, provide details of changes

Do you have a surgical suite?

Yes No

If Yes, is your surgical suite certified?

Yes No

If Yes, provide the name of the certification body

What percentage of your patients are under age 18?

Do you perform any hospital emergency room care?

Yes No

If Yes, is this solely a requirement for active admitting privileges?

Yes No

If No, provide detailed description including hours per month in emergency care

Do you perform consultations outside your primary state using telecommunications technology?

Yes No

If Yes, identify all states where such patients reside

What percentage of your total practice involves telemedicine?

Do you read, interpret or diagnose films/slides/specimens from patients in other states?

Yes No

If Yes, identify all states where such patients reside

Practice Details & Staff

Staff, patient load, income, and supervision details

Professional employees in your practice (check all that apply)

Physicians other than yourself Physician Assistants Nurse Practitioners Registered Nurses Licensed Practical Nurses Medical Assistants Laboratory/Radiology Technicians Other

If Other, describe

Are all staff members licensed in accordance with applicable regulations?

Yes No

If No, provide detailed explanation

Average weekly patient load

Number of patients annually

Average number of hours you practice each week

Approximate gross annual income from your practice

Do you supervise anyone other than your own employees?

Yes No

If Yes, provide detailed explanation of supervision responsibilities

Are all supervised individuals licensed appropriately?

Yes No

Specific Procedures & Services

Check all procedures you perform and indicate location

For each procedure you perform, indicate location: H = Hospital, O = Office, S = Surgi-center

Prior Professional Liability Insurance

Insurance history for the last 5 years

List prior Professional Liability Insurance for each of the last 5 years *

Does current policy allow reporting of incidents likely to result in a claim?

Yes No

Do any prior policies provide coverage for procedures not described in this application?

Yes No

Do any prior policies provide coverage for practice(s) not described in this application?

Yes No

Anesthesia Information

Details about anesthesia use in your practice

Is analgesia, sedation or anesthesia used on patients?

Yes No

Local anesthesia only

Yes No

Conscious sedation

Yes No

If conscious sedation, provide: % under 18, drugs used, location, duration of use, administered by

Deep sedation

Yes No

If deep sedation, provide: % under 18, drugs used, location, administered by

General anesthesia

Yes No

If general anesthesia, provide: % under 18, drugs used, location, duration of use, administered by

Are Harvard Standards for anesthesia administration adhered to?

Yes No

If No, explain

Have you completed an ACLS course?

Yes No

Do you hold a current ACLS certificate?

Yes No

If Yes, expiration date

If no ACLS, are you currently CPR certified?

Yes No

Is any member of your operating staff currently CPR certified?

Yes No

Anesthesia Training (check all that apply)

Completed ADA-accredited general anesthesia program (1+ year) Training included 6+ months general anesthesia Two+ years anesthesia training for certification

Are vital signs continuously monitored under sedation/anesthesia?

Yes No

If Yes, monitored by

You CRNA Anesthesiologist Other

Monitoring equipment available (check all)

Manual BP/heart rate Electronic BP/heart rate Precordial stethoscope EKG monitor Pulse oximeter Other

Emergency equipment available (check all)

Oral airway Oxygen Ambu bag Emergency drugs Endotracheal tubes/scopes Physician Anesthesiologist

Does your state require certificate/permit for general anesthesia or IV sedation?

Yes No

If Yes, certificate number

Date of renewal

Affiliations & Contracts

Employment, contracts, and other professional relationships

Are you employed by any individual, firm or corporation other than your primary practice?

Yes No

If Yes, provide detailed explanation including responsibilities

Are you under contract to any individual, firm or corporation other than your primary practice?

Yes No

If Yes, provide detailed explanation including responsibilities

Does any contract contain a hold harmless agreement?

Yes No

Are you employed by or under contract to any governmental entity?

Yes No

If Yes, provide detailed explanation including responsibilities

Do you advertise your services other than simple telephone listing?

Yes No

Are you associated with any agency that engages in advertising/solicitation of patients?

Yes No

Are you Medical Director of a nursing home, clinic, or other organization?

Yes No

If Yes, provide detailed explanation

Do you have any administrative or teaching responsibilities?

Yes No

If Yes, provide entity name, location, your title

Does the entity provide coverage for your administrative responsibilities?

Yes No

Does the entity provide coverage for your direct patient care?

Yes No

Do you work for any locum tenens companies?

Yes No

Do you provide services to inmates in correctional facilities?

Yes No

If Yes, provide details

Are you engaged in any 'moonlighting' activities?

Yes No

If Yes, do you want coverage for moonlighting activities?

Yes No

If Yes, describe the activities

Claims & Legal History

Any claims, investigations, or legal issues

Has any malpractice claim or suit ever been made against you or your entity?

Yes No

If Yes, how many?

Any malpractice claims that have not been reported to current or prior insurer?

Yes No

If Yes, how many?

Are you aware of any act, error, omission, or circumstance that may result in a claim?

Yes No

If Yes, how many?

Have you ever been investigated or had proceedings to deny/limit/suspend privileges?

Yes No

Has your license ever been limited, suspended, revoked, or placed on probation?

Yes No

Have you ever been investigated by any licensing or regulatory agency?

Yes No

Have you ever been charged with or convicted of any violation of law or ordinance?

Yes No

Have you ever been evaluated, treated or hospitalized for alcohol/substance abuse or mental/emotional disorders?

Yes No

Do you have any physical/mental disability that would limit your ability to safely practice?

Yes No

Coverage Needs

Desired coverage limits and options

Desired Liability Limits *

Do you need prior acts coverage?

Yes No

Additional Coverages Desired

Legal Defense License Protection Medical Payments Assault Coverage Personal Injury Property Damage Other

Additional Information

Any other details we should know

Additional information or special circumstances

Preferred Contact Method

Best Time to Contact

Your information is secure and will only be used to provide an insurance quote.

★★★★★

"I run 22 trucks across the tristate. Austin consolidated everything under one policy and the premium dropped."

— Jorge V., Trucking — Queens NY

★★★★★

"Austin saved me $700/year on auto and got better home coverage for half the price."

— Michelle T., Homeowner — Cos Cob CT

★★★★★

"Justin put together a life insurance plan that actually made sense. No pressure, just options."

— Brian W., Business Owner — Westport CT

★★★★★

"Their tech is unreal. All my policies, renewals, and certs in one dashboard. No other agency has this."

— Alex F., Property Manager — Manhattan NY

★★★★★

"We needed builder's risk same day for a closing. Eric made it happen. No drama, no excuses."

— Nick G., Developer — Stamford CT

★★★★★

"10 rental properties insured through Safeshield. Re-shopped every one and found savings on 8."

— Linda C., Real Estate — Norwalk CT

★★★★★

"They monitor our renewals 60 days out. Got a call saying they saved us $2K before renewal even hit."

— Steve H., Restaurant — Fairfield CT

★★★★★

"Eric walked us through our umbrella options like a teacher. Patient and genuinely cared."

— Diane M., Homeowner — New Canaan CT

★★★★★

"I run 22 trucks across the tristate. Austin consolidated everything under one policy and the premium dropped."

— Jorge V., Trucking — Queens NY

★★★★★

"Austin saved me $700/year on auto and got better home coverage for half the price."

— Michelle T., Homeowner — Cos Cob CT

★★★★★

"Justin put together a life insurance plan that actually made sense. No pressure, just options."

— Brian W., Business Owner — Westport CT

★★★★★

"Their tech is unreal. All my policies, renewals, and certs in one dashboard. No other agency has this."

— Alex F., Property Manager — Manhattan NY

★★★★★

"We needed builder's risk same day for a closing. Eric made it happen. No drama, no excuses."

— Nick G., Developer — Stamford CT

★★★★★

"10 rental properties insured through Safeshield. Re-shopped every one and found savings on 8."

— Linda C., Real Estate — Norwalk CT

★★★★★

"They monitor our renewals 60 days out. Got a call saying they saved us $2K before renewal even hit."

— Steve H., Restaurant — Fairfield CT

★★★★★

"Eric walked us through our umbrella options like a teacher. Patient and genuinely cared."

— Diane M., Homeowner — New Canaan CT

★★★★★

"COI to the GC in under 15 minutes. Every. Single. Time. Worth switching for if you're in the trades."

— Vinny A., Painting — Brooklyn NY

★★★★★

"Austin found gaps in my coverage I had no idea existed. For a high-value home, that matters."

— Robert K., Homeowner — Greenwich CT

★★★★★

"Old agent took 3 days for a certificate. Safeshield does it in minutes. Speed is money."

— Carlos R., Concrete — Yonkers NY

★★★★★

"Justin set me up with term life and disability. Sole proprietor — family needs to be covered."

— Mike T., Electrician — Trumbull CT

★★★★★

"Moved my restaurant's commercial package and liquor liability. Better coverage, lower premium."

— Anna P., Restaurant — Stamford CT

★★★★★

"He made me feel like a human being, not a policy number. All 4 of my businesses are here now."

— David N., Multi-Business — White Plains NY

★★★★★

"They shopped 73 carriers for our commercial property. We would've overpaid by $6K if we'd just renewed."

— Frank J., Property Mgmt — Bridgeport CT

★★★★★

"Eric handles our entire book. Whenever I need something, I text him and it's done. That simple."

— Sophia L., Client — Darien CT

★★★★★

"COI to the GC in under 15 minutes. Every. Single. Time. Worth switching for if you're in the trades."

— Vinny A., Painting — Brooklyn NY

★★★★★

"Austin found gaps in my coverage I had no idea existed. For a high-value home, that matters."

— Robert K., Homeowner — Greenwich CT

★★★★★

"Old agent took 3 days for a certificate. Safeshield does it in minutes. Speed is money."

— Carlos R., Concrete — Yonkers NY

★★★★★

"Justin set me up with term life and disability. Sole proprietor — family needs to be covered."

— Mike T., Electrician — Trumbull CT

★★★★★

"Moved my restaurant's commercial package and liquor liability. Better coverage, lower premium."

— Anna P., Restaurant — Stamford CT

★★★★★

"He made me feel like a human being, not a policy number. All 4 of my businesses are here now."

— David N., Multi-Business — White Plains NY

★★★★★

"They shopped 73 carriers for our commercial property. We would've overpaid by $6K if we'd just renewed."

— Frank J., Property Mgmt — Bridgeport CT

★★★★★

"Eric handles our entire book. Whenever I need something, I text him and it's done. That simple."

— Sophia L., Client — Darien CT

SAFESHIELD INSURANCE We Work For You. Not The Insurance Company.