Dental Hygienist Professional Liability
Application for Insurance







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Occurrence / Aggregate


















































































The professional liability coverage you are applying for does not provide product liability coverage











































I have completed the hygienist professional liability application after verifying the accuracy of the information provided and I declare and represent that all of the information provided is true, correct and complete to the best of my knowledge. I also acknowledge a continuing obligation to report to the company, as soon as practicable, any material changes in the representations and statements above, and in each supplemental application, that I become aware of after signing the application. (I also understand that any material misrepresentation or omission made by me on this application may act to render any contract of insurance null and without effect or provide the company with the right to rescind it.)*
*not applicable to AK, AZ & GA applicants

If a policy is issued by the company, it will be in reliance on the accuracy of the information provided in this application. If you accept the policy issued by the company, you agree that the statements in this and any other application submitted to the company are true and correct.

Claims-made notice
If you have selected the claims-made option, the professional liability coverage will apply on a "Claimsmade and reported basis". The insuring agreements include special requirements for providing timely, written notice to the company. Please read the policy carefully.

If you fail to report any claim made against you during your current policy term or fail to report circumstances which may give rise to a claim to your current insurance company before policy expiration, the claim may not be covered.





Please be advised that the representations made in the application are incorporated by reference into the policy if a policy is issued.

This product is underwritten by © Pharmacists Mutual Insurance Company.

PM 907 0216

FRAUD STATEMENTS

Agency: PHARMACISTS MUTUAL INSURANCE COMPANY
Carrier: PHARMACISTS MUTUAL INSURANCE
NAIC Code: 13714
Applicant / Named Insured:

Applicable in AL, AR, DC, LA, MD, NM, RI and WV
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only. Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only.
Applicable in CO
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in FL and OK
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)*. *Applies in FL Only.
Applicable in KS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in KY, NY, OH and PA
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 information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only.
Applicable in ME, TN, VA and WA
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.
Applicable in NJ
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Applicable in OR
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.
Applicable in PR
Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.





ACORD 63 (2016/10)

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The ACORD name and logo are registered marks of ACORD.

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