Application For Individual Pharmacist Professional Liability Insurance

DESIGNED SPECIFICALLY AS AN EXCESS POLICY

ANSWER ALL QUESTIONS - An incomplete application will be returned
Coverage Limits - $1,000,000 per occurrence/$3,000,000 aggregate


Name:      
Mailing Address: City:
State: Zip: County:  
Is this address located within city limits?
E-mail:
Home Phone: Work Phone: Cell Phone:
Birthdate:
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.
Owner or Partner of a Pharmacy or Pharmacy-related business

An Owner or a Partner of pharmacy or pharmacy related businesses.

Pharmacy Business Professional Liability Insurance:

Business Name:
Business Address:
Employed Pharmacist (receive IRS Form W-2 Wage and Tax Statement)

An individual who is a licensed and registered pharmacist. Includes an employee of a community pharmacy, chain pharmacy, hospital or other facility where an IRS W-2 Form Wage & Tax Statement is received at year end. Also includes pharmacy students who have completed their state boards and are licensed.

Employer Name:
Employer Address:
Self-Employed Relief/Independent Contractor Pharmacist (receive IRS Form 1099-MISC)

Contact Pharmacists Mutual Insurance Company at 800.247.5930 or email us at info@phmic.com concerning other important coverages you may need.

Self-Employed Consultant Pharmacist (receive IRS Form 1099-MISC)

Contact Pharmacists Mutual Insurance Company at 800.247.5930 or email us at info@phmic.com concerning other important coverages you may need.

Instructor at accredited school or facility

Works as a classroom instructor at an accredited school of pharmacy or pharmacy educational facility and works less than 10 hours per week outside of the classroom as an employed or self employed pharmacist.

School:
Pharmacy Student/Intern

A pharmacy student who has not yet completed the state boards and is not registered. This would include undergraduate students, interns and graduate students.

School:
Expected Graduation:
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.


Signature: Date:
PM 76 1113
FRAUD STATEMENTS
Agency: PHARMACISTS MUTUAL INSURANCE COMPANY Carrier: PHARMACISTS MUTUAL INSURANCE
NAIC Code: 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 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 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.
Signature: Date:
ACORD 63 (2013/09)
© 1997-2013 ACORD CORPORATION. All rights reserved.
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.




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