Application for Professional Liability Insurance
DESIGNED SPECIFICALLY AS AN EXCESS POLICY

$
Increased Liability Limit $
Advanced Pharmacist License Coverage $
$
-$
$
Total Policy Premium $
*Additional taxes may apply
If you need to change the address on one of your existing policies, please visit our Member Portal.
An owner or a partner of a pharmacy or pharmacy related businesses.
An owner or a partner of a pharmacy or pharmacy related businesses, with the exception of a sole proprietor.
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 and Tax Statement is received at year end. Includes a pharmacy student who has completed state boards and is licensed.
Includes a pharmacy technician employee where an IRS W-2 Form Wage & Tax Statement is received for wages earned. Must not be an owner or partner of a pharmacy or pharmacy related business. May work less than 10 hours as a self-employed pharmacy technician. This also includes an employed pharmacy technician in training.
(receive IRS Form 1099-MISC or 1099-NEC). Contact Pharmacists Mutual Insurance Company at 800.247.5930 ext. 4050 or email us at info@phmic.com concerning other important coverages you may need.
Includes a self-employed pharmacy technician who receives IRS Form 1099-MISC or 1099-NEC. Must not be an owner or partner of a pharmacay or pharmacy related business other than a sole proprietor.
(receive IRS Form 1099-MISC or 1099-NEC). Contact Pharmacists Mutual Insurance Company at 800.247.5930 ext. 4050 or email us at info@phmic.com concerning other important coverages you may need.
A Pharmacist who works as a classroom instructor at an accredited school of pharmacy or pharmacy educational facility. May also work less than 10 hours per week as an employed or self-employed pharmacist.
Works as a classroom instructor at a pharmacy technician educational facility. May work less than 10 hours per week outside of the classroom as an employed or self-employed pharmacy technician.
A pharmacy student who has not yet completed the state boards and is not registered. This would include undergraduate students, interns and graduate students.

If more than one classification applies, please call 800.247.5930 ext. 4050 for a proposal.

If working more than 10 hours per week outside of the classroom, please call 800.247.5930 ext. 4050 for a proposal.

This includes performing or supervising the performance of IV admixture program.
This policy provides coverage on a claims-made & reported basis with special requirements for providing notice to the company.

Since your business professional liability insurance is with another carrier, we will require proof of insurance prior to issuing your pharmacy professional liability policy.

If you are still a student, enter your projected graduation month.
If you are still a student, enter your projected graduation year.
Advanced Pharmacist License means a license that allows an additional scope of practice authority based on the specific rules outlined in the state. This may include providing direct patient care under an agreement with a supervising physician Advanced Pharmacist License designations include Advanced Practice Pharmacist, Clinical Pharmacist Practitioner, or Pharmacist Clinician.
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(not applicable for MO residents)
Proof of current Professional Liability Policy will be required before policy is issued.
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.
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© 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.
ACORD 63 (2016/10)

© 1997-2016 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.
Contact Pharmacists Mutual Insurance Company at 800.247.5930 or email us at info@phmic.com concerning other important coverages you may need.
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