APPLICATION TO ADD A PHYSICIAN, SURGEON TO AN ENTITY POLICY/QUOTE Admiral Insurance Company Add Provider Application - Short Form Entity Info:Policy / Quote #: _______________________ Services Provided At: Cirrus Medical Network, LLC 10627 Professional Cir, Ste A Reno, NV 89521 CirrusMED.com Physician's Personal InformationName First Last DegreeMDDOMailing Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (if different from the entity)Primary State Medical License* Primary State Medical License #* Other State Medical Licenses and NumbersExample: CA #GT1234, UT #7890 Date of Birth* Month Day Year Place of Birth* Medical School* Year of Graduation* Medical Specialty Sub-Specialty Untitled Are you American Board Certified? Yes No Board Eligible Board Certification Specialty Year Certified? What is your relationship to the entity?* Independent Contractor Owner/Partner Employee Volunteer Treating Physician Services InformationPlease describe, in detail, the medical services you provide:How many hours per week are dedicated to providing medical services for this Entity? Estimated hours of actual patient care. Average is 7-10 hrs. How many patient encounters per week do you have at this facility? Estimate the number of patient encounters (appointments and/or patient interactions via messaging/video chat) per week. Average is 20-30 per week. How long have you worked as a treating physician at this facility? Medical Director Services InformationDo you also provide medical director services at this facility? Yes No How many hours per week are dedicated to medical director services only? How long have you worked as medical director at this facility? Please describe your duties as medical director Prior/Other Insurance InformationDo you provide medical services outside of this facility? Yes No Please provide the following Medical Malpractice Insurance Information (or attached a copy of your Declarations of Certificate of Insurance):CompanyPolicy NumberTermLimits of LiabilityRetro Date Claim InformationHas any claim ever been made against you as respect to your duties as a medical director? Yes No Are you aware of any circumstances as respects your duties as a medical director which may result in a claim against you? Yes No If Yes, please provide details: Has any claim ever been make against you for Medical Malpractice? Yes No If Yes, complete the Supplemental Claim Information Form for each claim. Also please attach five years of currently valued company loss runs. Are you aware of any circumstances as respects your duties as a treating physician which may results in a claim against you? Yes No If Yes, please provide details:Applicant Warranty:The applicant declares that the above statements and representations are true and correct and that no facts have been suppressed or misstated. The completion of this application does not bind the Company to sell, nor the applicant to purchase this insurance, but any subsequent contract issued will be in full reliance upon the statements and representations make in this application and this application will be made a part of this policy. The applicant understands that any subsequent contract issued by the Company will be issued on a CLAIMS MADE FORM.SignatureDate MM slash DD slash YYYY Upload Copy of CVMax. file size: 256 MB.Upload a minimum of five years of currently valued company loss runsMax. file size: 256 MB. Δ SUPPLEMENTAL CLAIMS INFORMATION FORM (Complete one form for each claim) Type of Claim Medical Director Medical Malpractice Claim Name of applicant/named insured: First Last Name of other parties or defendants named in suit: Date of alleged error or occurrence, or contact date: Date claim was made: DD slash MM slash YYYY Name of claimant: Name of Insurance Company handling your claim: Present status of claim or final disposition: Choose One: CLOSED OPEN Defense costs paid to date inclusive of any deductible: If closed, total loss paid, inclusive of any deductible: If claim is open or pending, what are the insurers reserves?Defense:Loss:Description of case and events including allegatioins and assessment of liability:Claimants last settlement demand: Date MM slash DD slash YYYY Signature Δ
