Do you manufacture or wholesale any drugs or drug products? *

If Yes, please explain: *

Do you have an individual professional liability policy with another carrier? *

If Yes, please explain: *

Have you ever had professional liability insurance declined, cancelled, or non-renewed for any reason other than for non-payment of premium? *

If Yes, please explain: *

Has any claim or lawsuit for professional liability ever been brought against you or are you aware of any incidents that may result in a claim or lawsuit? *

If Yes, please explain: *

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? *

If Yes, please explain: *

Primary Practice Setting: * Ambulatory Clinic Care Facility (Nursing Home, LTC, Extended Care) Chain Pharmacy Community or Independent Pharmacy Home Health Care Home Infusion Hospice Hospital Pharmacy Internet Pharmacy Mail Order Pharmacy Nuclear Pharmacy Outsourcing Facility Staffing Agency Other

If Internet Pharmacy, please provide web site: *

If Other, please specify: *

Do you currently have any Pharmacist Mutual policies? *

If No, have you had a policy with Pharmacists Mutual in the past? *

If Yes, what type of policy did you have in the past? *

If Yes, please provide policy number or member number: *

Have you ever been known by another last name? *

If Yes, please provide former last name: *

Do you have a current claims-made policy? *

If Yes, enter your retroactive date: * Proof of current Professional Liability Policy will be required before policy is issued.

First Name: *

Middle Initial:

Last Name: *

Birthdate: *

License Number: *

Do you maintain a license, certificate or registration as a pharmacy technician? *

List additional information about license, certificate or registration and any additional states licensed, certified or registered in:

List additional states and license numbers in box below:

Mailing Address: *

State: * AK AR AL AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VT VA WA WI WV WY

City: *

Zip: *

Province/ County: *

Country: * USA Canada

Primary Email: *

Secondary Email:

Home Phone: *

Work Phone:

Cell Phone:

This application does not bind coverage. Coverage is effective when policy is issued.

FRAUD STATEMENT
NEW YORK

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 shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Applicant Signature: * PM 1161 0314

© 2014, Pharmacists Mutual ® Insurance Company

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, 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. Applicant Signature: * ACORD 63 (2016/10)

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The ACORD name and logo are registered marks of ACORD.

Applicant Signature: *

Date: *

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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