Is this address located within city limits?
Effective date of the policy:
State in which you are licensed:
License number (intern number if student):
Year of Graduation:
List additional states and license numbers in box below:
If more than one classification applies, please call 800.247.5930 for quote.
Where is your primary practice setting:
Do you perform sterile compounding (this includes performing or supervising the
performance of IV admixture program)?
Do you have an individual professional liability policy with another carrier?
Do you compound in batch, manufacture or wholesale any drugs or drug products?
Have you ever had professional liability insurance declined, canceled, or non-renewed
for any reason other than for non-payment of premium? (not applicable for MO residents)
Has any claim or lawsuit for Pharmacy Professional Liability ever been brought against
you or are you aware of any incidents that may result in a claim or lawsuit?
Within the last 5 years, have you been the subject of complaints, charges, or disciplinary
action for any reason, by a court, regulatory agency or Board of Pharmacy?
This application does not bind coverage. Coverage is effective when policy is issued.
PM 76 1113
PHARMACISTS MUTUAL INSURANCE COMPANY Carrier:
13714 Applicant/Named Insured:
Applicable in AL, AR, AZ, DC, LA, MD, NM, RI and WV
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
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 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
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 (2013/09)
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The ACORD name and logo are registered marks of ACORD.
By submitting this application, I affirm the information submitted is true
and understand this information forms the basis upon which the policy is issued.