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Application Requirements

Documents Required for Accurate Premium Indication

A) Current copy of each physician’s Curriculum Vitae (CV)

B) Copy of declaration page for currently enforced Professional Liability Insurance policy which includes policy limits and policy type (not a certificate of insurance from the agent)

C) Claims-made, modified claims-made, occurrence, effective and retroactive dates, and medical specialty

D) Copy of all “on-hand” loss information: old loss runs, copy of credentialing forms submitted to hospitals that include loss information, old medical-liability insurance applications, letters of dismissal or other court orders, along with the names and phone numbers of current and/or past defense counsel

Additional Documents Required

A) Copy of National Practitioners Data Bank (NPDB) Self-Query report. This takes about 30 minutes to complete and mails at a cost of around $16. It is good for physicians to regularly check NPDB for accuracy. The physician will need all current and expired state medical license numbers, DEA numbers, unique identifier numbers, etc. prior to going online: Click Here

B) Copy of Florida Disciplinary Licensing Action report

C) Signed and dated No Known Losses Form

D) Signed and dated Application Acknowledgement Form

E) Signed and dated Supplemental Claims Form for all pending / open claims, notices, demands, and/or lawsuits

F) Completed applications should be signed, dated and mailed to the address found on our “Contact Us” page

G) If submitting an application other than Lancet’s Please provide Lancet’s No Known Loss Form and Lancet’s Warranty Page

H) If there are additional insureds we will need either the Professional or Corporation supplemental filled out.

I) If the policy if going to be Retro Date Inception (RDI) we will need a Waiver of Prior Acts form Filled out.

J) Underwriting may require supplemental applications based on specialty. These can be provided on an as needed request.

Applications

Lancet Application

Renewal Application

Para Professional Application

Corporation Partnership or Other Legal Entity Professional Liability Insurance Application

Additional Documents

No Known Loss

Prior Acts Coverage

Lancet Warranty

Claims Form

Waiver of Prior Acts

Entity Additional Insured

Professional Additional Insured