Voluntary Attending Physicians & Surgeons Professional ...7. Primary Email address: 8. Website address: 9. Primary Office Address (where you see the majority of your patients): Number

Voluntary Attending Physicians & Surgeons Professional Liability Insurance

Application

(PHYApp 5/2020)

Please complete the application and sign and date where applicable. Return this application with all required attachments by email or fax. If a question is not applicable, please write “N/A”. Please make sure to include all required attachments so that we may process your application promptly.

Insurance coverage is subject to underwriting approval and payment of premium. No coverage exists until the initial premium is received and a policy with all applicable endorsements has been issued to the named insured.

Required Attachments:

• Copy of your New York State professional license• Curriculum vitae• Declarations page from your current insurance policy, primary and excess (if applicable)• Loss runs from all carriers that insured you for the past seven years• Copy of NYS approved Risk Management course certificate (taken within the past two years)

Important Notice: please read carefully Claims-made policies generally cover incidents and events that both happen and are reported to us while you have a policy with The Hospitals Insurance Company, Inc. Coverage is only provided for incidents that occur on or after the retroactive date stated in the policy and which are reported to us while the policy is in effect or within 60 days following termination of coverage. You can also elect to purchase extended reporting, or tail coverage which will allow you to report claims that arise out of incidents occurring after your retroactive date but before you ended your policy with us , but which are reported after you end your coverage with us.

During the first several years, claims made premiums are lower than occurrence premiums, but then they increase substantially, independent of overall rate level increases, until the claims made risk reaches maturity.

If you are switching from a claims-made to an occurrence policy, you should consider purchasing extended reporting coverage to cover any claims that may arise while you were insured with your prior carrier.

Occurrence policies cover incidents that happen while you were covered by a policy issued by Hospitals Insurance Company, Inc., but can be reported anytime, even if you are no longer insured with us.

If you have any questions about this application, please contact the Hospitals Insurance Company, Inc. Underwriting Department at 800.982.7101. Please return this application with all required attachments by either email, fax or mail.

(PHYApp 5/2020) Page 1

Email: [email protected]: 212.702.6359Mailing address: Underwriting and Physician Services

Healthcare Risk Advisors 111 West 33rd Street, 8th Fl. New York, NY 10120

mailto:[email protected]


1. Please select the requested coverage: Claims-Made Occurrence

2. Requested effective date (coverage start date): 12:01 A.M. Standard Time

3. Prior Acts (retroactive coverage): complete only if you are not purchasing an extended reporting period endorsement (Tail) from your current carrier, and you are replacing an existing Claims-Made policy. Requested prior acts date:

If prior acts coverage is not being requested, are you purchasing extended reporting coverag e from your prior carrier? Yes NoIf yes, please provide proof of tail coverage. If no, please explain in Section IX. Additional Remarks.

Do you know of any incidents that may lead to potential claims for professional services you provided that occurred during the period for which prior acts coverage is desired, that have not been reported to your previous carrier? Yes NoIf yes, please explain in Section X. Additional Remarks.

4. Section 18 Excess professional liability insuranceExcess professional liability occurrence coverage with limits of $1,000,000/$3,000,000 is available at no additional charge for eligible physicians. If you currently have excess coverage with another carrier or are requesting coverage with HIC for the first time, please complete the attached Section 18 Excess Professional Liability Insurance Application and submit along with this application.

1. Please select the hospital where you maintain hospital privileges. The hospital selected will bedesignated as your sponsor hospital.

2. It is a requirement of the Hospitals Insurance Company, Inc. Voluntary Attending Physician (VAP) Program that physicians who admit 50 or more patients per year for hospitalization, admit at least halfof these admissions to his/her sponsor hospital. Please complete the table with the following information.

a. Indicate each hospital, nursing home, managed care facility and/or other health care facility where you have had privileges to treat patients during the past 12 months or to which you are applying for privileges.

BronxCare Health System Mount Sinai Hospital Maimonides Medical Center Mount Sinai Beth Israel Montefiore Medical Center Mount Sinai Brooklyn Montefiore Mount Vernon Mount Sinai Queens Montefiore Nyack Hospital NYE&E of Mount Sinai White Plains Hospital Mount Sinai West/St. Luke’s St. Luke’s Cornwall Hospital Mount Sinai South Nassau

Section II. Coverage Type

Section III. Sponsor Hospital


Section I. Limits of Liability

$1,000,000 Each Person / $3,000,000 Total Liability0$1,300,000 Each Person / $3,900,000 Total LiabilityPlease0,ooo Each Person

b. Provide the projected number of admissions, consultations and/or procedures performed at eachfacility. (If additional space is needed, please add to Section X. Additional Remarks).

Facility Admissions Consults

Surgeries/ Deliveries/ Procedures

Ambulatory Surgeries/ Procedures

Title (MD,DO,DMD): 1. Name (First,MI,Last):

2. Date of birth: 4. Gender: M F

5. NYS License number:

3. Social Security No.:

6. Nation al Provider ID:

7. Primary Email address: 8. Website address:

9. Primary Office Address (where you see the majority of your patients):

Number & Street City State Zip Code

Office Phone No. Fax No.

10. Other office location(s) for which coverage is desired(If more space is needed, please list additional locations in Section X. Additional Remarks).

Number & Street City State Zip Code

Office Phone No. Fax No.

City State Zip Code

11. Home Address:

Number & Street

Office Phone No.

Section IV. General Information


Fax No.

All correspondence will be sent to the above primary email, but your consent is required. Refer to the CONSENT FOR USE OF ELECTRONIC DOCUMENTS AND SIGNATURE at the back of this application. If you do not consent to email, all correspondence will be sent to your primary office unless you specify your home address by checking here .

1. Medical Education:

Medical School State Country Graduation Date 2. Post Graduate Medical Education:

a. Internship:

Hospital: From: (Mo/Yr.) To: (Mo/Yr.)

b. Residency:Hospital From: (Mo/Yr.) To: (Mo/Yr.)

Specialty

c. Fellowship:Hospital From: (Mo/Yr.) To: (Mo/Yr.)

3. Explain any gaps in time from date of medical school graduation to completion of residency.

Yes No 4. Board Certification:

a. Are you ABMS or AOA Board certified?b. Are you Board certified in your Sub-specialty? Yes No

No

Date Certified: Date Certified: Date Eligible:

If additional space is needed, please use Section X. Additional Remarks.

1. Do you have a license to practice outside of New York State? Yes No 2. What percentage (%) of your practice is located outside of New York State?3. Provide state(s) and license number(s):

4. Status of other license(s):

5. Do you participate in telemedicine? Yes No No If yes, do you provide these services outside of New York State? Yes

If yes, please list to whom you provide these services, including the city and state.

Section V. Education Information

Section VI. Practice Information

%


c. Are you American Board eligible in your Specialty? Yes

State: L icense #

6. Are you licensed to practice medicine in the state(s) listed? Yes No If yes, please provide a copy of the license(s).

7. Do you or your professional entity employ other physicians or surgeons? Yes No If yes, please provide the following:

Name Specialty PL Insurance

8. Do you individually, or does your professional entity, employ or contractwith any midwife, nurse-anesthetist, nurse-practitioner, podiatrist,chiropractor, radiation therapist, physician’s assistant or registeredspecialist’s assistant?

Yes No

If yes, please provide the following:Name/Professional Designation License No.

Please note that your HIC policy will not provide coverage for your liability arising out of the acts or omissions of any employed physicians, dentists, nurse-midwives, nurse-anesthetists, nurse- practitioners, podiatrists, chiropractors, radiation therapists, physician’s assistants or registered specialist’s assistants.

9. Are you a medical director, department head or chief of staff at a hospital, nursinghome, HMO, managed care facility, medical spa or other health care facility? Yes No If yes, please provide facility names and insurance carriers.

Facility Insurance Carrier

10. Do you own or operate a hospital, nursing home, clinic, laboratory, or othermedically related business? Yes No

If yes, please provide the following:

Corporate Name Type

Operations Relationship Insurance

Carrier


11. Have you signed, or will you sign any contract or agreement to assume the Yes Noliabilities of others?Please note that your HIC policy will not provide you with coverage for liability of others that youassume by contract or agreement.

12. Statements of Insurance: Please indicate to whom statements are to be sent. Include mailing address.Facility Name Address

If your answer is yes to questions #2 to #15, please explain in Section X. Additional Remarks and attach any additional documentation.

1. Have you ever had professional liability insurance?Yes No If yes, please list all past insurance coverages.

Policy Period Insurance Carrier Policy # Policy Type

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Section VII. Insurance Information


2. Has any insurer ever canceled, declined, refused to renew, or restricted professional liability insurance to you, or offered such insurance to you with a deductible or at higher than regular rates?

3. Have you ever been required to pay a premium surcharged by any insurer?

4. Have you ever practiced without professional liability insurance?

5. Are you aware of any circumstances that might be reasonably expected to lead to a claim or suit (even if you believe the possible claim or suit would be without merit) that have not been reported to your current or prior medical professional liability carrier?

6. Have you been a party to a malpractice claim, suit or incident in the past ten years?If yes, please provide details in Section IX. Claims/Lawsuit Information.

7. Has your license to practice ever been revoked, suspended or restricted in any state?

8. Has your license to practice ever been voluntarily surrendered?

9. Have you ever been placed on probation in any state?

10. Has your permit to prescribe medications ever been denied/revoked, restricted/ voluntarily surrendered?

11. Are there any investigative or disciplinary actions by any governmental agency currently pending against you in any state?

Solo Practitioner

Independent Contractor

Solo Professional Corporation

Medical Partnership

Other:

12. Do you have any health problem(s), illnesses or physical condition(s) that wouldimpair or could tend to impair your ability to practice your medical specialty? Yes No

13. Have your privileges ever been revoked, restricted or suspended by anyhospital/other institution/managed care organization? Yes No

14. Have you ever voluntarily relinquished privileges at any hospital/otherinstitution/managed care organization? Yes No

15. Are there currently any disciplinary proceedings pending against you? Yes No

If additional space is needed, please use Section X. Additional Remarks.

1. Specialty: Percentage of practice: Percentage of practice: Sub-specialty:

(Refer to Specialty Classifications sheet)

2. Do you perform any procedures for which you did not receive training in yourresidency or that are outside the customary scope of practice of your specialty?

Yes No

If yes, please list the procedures:

3. Do you perform office-based surgical or invasive procedures that require more than Yes No

AAAHC AAAASF

4. Practice: Please select all that apply to your practice situation:Employee (partnership, professional corporation, group, physician/surgeon, hospital, nursing home, managed care facility, other health care facility)

Professional Corporation (more than one physician shareholder)

5. Office Practice Hours: Full Time Part Time

a. Average number of patients seen at your office per week:

b. Hours per week for which you require coverage:

c. If part time, indicate the number of hours per week that areor will be covered by insurance other than HIC:

Section VIII. Underwriting Information

%%


mild sedation?If yes, please select the agency that accredits your practice:

TJC

List other insurance carrier, coverage type (CM/Occ) and Limits of Liability

Insurance Carrier Policy Type Limits of Liability

Part Time Practice only: Includes all professional activity as a physician or surgeon, including patient care, telemedicine, record keeping, consultation, hospital rounds, accreditation and other review functions on behalf of a hospital, long-term care facility, medical group or professional society. A change in status from Full Time to Part Time may be considered after a six-month period has elapsed. Note: The Part-Time Practice discount applies only if the total weekly practice hours do not exceed 20 hours.

6. Professional entity coverage is available under an individual physician’s HIC policy only if 50% ormore of the entity owners maintain primary professional liability coverage with HIC. Pleaseprovide the name and primary professional liability insurance carrier for each entity owner.Incomplete information or a change in entity ownership to below 50% after the date thisapplication is received may preclude issuing entity coverage to your corporation.

Entity Owner Name Primary PL Insurance Carrier

For an additional premium, you may apply for separate coverage with Limits of $1,000,000/$3,000,000 for your Professional Entity that will require a separate application to be completed. To request an application please contact us at 212.891.0844

7. Please select procedures that you currently perform or are considering performing in the future.

Acupuncture* Culdocentesis Hysterectomy Pacemaker Coronary Angiograms Diagnostic D&C IVF Phalloplasty Coronary Angioplasty EST Laparoscopy Tubal Ligation Appendectomy Endometrial Biopsy Liposuction Vein Stripping Cardiac Catheterization Endoscopic Procedures Mohs Microsurgery Weight Control: Circumcision (adult) ERCP Nasal Polypectomy Diet Circumcision (pediatric) Hair Transplants Orchiectomy Medication Colonoscopy Hydrocelectomy Organ Transplants

*Acupuncture: submit copy of NYS certification


8. Family/General Practice Specialties: Please include the # of procedures (office and hospital practice) youcurrently perform or anticipate performing in the next 12 months.

Herniorrhaphies Open Reduction (Fracture) Prenatal care Termination of Pregnancy (up to 12 weeks) Tonsillectomy Varicose vein surgery

Adenoidectomy Assist at major surgery Closed reduction (Fracture) Deliveries Diagnostic D&C Excision of superficial growths Hemorrhoidectomies Vasectomies

Other major/minor procedures not listed in this application:

9. Please indicate if you or your staff perform any of the following procedures.

Non-Licensed Staff Physician Licensed

Botox injection

Chemical Peel Cosmetic

Tattooing Dermal

Fillers

Laser Hair Removal

Laser Wrinkle Removal

Microdermabrasion

Sclerotherapy

Other: (describe below)

Please attach a detailed description of training and certificates of completion for each identified as performing procedure(s).

Yes No 10. Anesthesiology

a. Do you administer anesthesia outside of a hospital setting?If yes, please list location(s):

b. What is the distance to the nearest hospital?What emergency equipment is available on site?

c. Do you employ or supervise CRNAs? Yes No If yes, please complete the following:# employed # supervised

d. Do CRNAs give anesthesia while not under your personal direction,Yes No control, or supervision?If yes, please describe:


Please indicate the procedures that you perform or will perform with the corresponding percentage ofpractice for each:

Bariatric %

11. General/Specialty Surgery

General %Thoracic (cardio) %Thoracic (non-cardiac) %Vascular %Other: %

Do you perform colon and rectal surgery? Yes No

If yes:

a. Do you limit surgery to the rectum, anal canal, and perineal area Yes No

b. Is any of your surgery performed by the abdominal approach Yes No

No

Non-Hospital

b. Do you provide direct patient treatment (not limited to obstetrical care)

Yes No during delivery (including the immediate labor, puerperal and/or neonatalperiod) in any facility other than a licensed acute care hospital?If yes, please provide full details:

Yes No Yes No

Yes No

Yes No

c. Termination of Pregnancy:i. Medical abortions:ii. Suction curettage:

Limited to the first 12 weeks of pregnancy?Beyond the first 12 weeks of pregnancy?

iii. Other, explain:

d. Location: Please provide the number of procedures performed monthly at each location. Office Hospital Clinic Other

% %

13. OphthalmologyPlease indicate, using percentage (%) how much of your practice is dedicated to each.

a. Office practiceb. Minor surgical procedures (Laser, assisting in surgery)c. Major surgery (considers all procedures) %


12. Obstetrics and Gynecologya. Is your practice limited to gynecology only (including gynecologic surgery)? Yes

Please indicate the number of deliveries you perform annually:

Normal Vaginal C-Section VBAC High Risk

Yes No

Yes No

14. Otolaryngology/Cosmetic Plastic SurgeryIf you are applying for coverage in otolaryngology including cosmetic plasticsurgery, is cosmetic plastic surgery limited to the field of otolaryngology?

15. Pain ManagementDo you perform pain management procedures?If yes, please complete the following:

Nerve Blocks/Injections % Brachial % Cervical % Epidural %

% % %

Peripheral Sympathetic Thoracic Other (explain below):

Procedures/Implants/Insertions Kyphoplasty Vertebroplasty MILD Spinal Infusion Pump Spinal Infusion Implant Spinal Stimulation Implant Dorsal Column Stimulator Implants % Epidural or Spinal Catheter %

Discounts

Yes No

a. Risk ManagementAre you receiving a premium discount as a result of having completed a NewYork State Department of Financial Services approved Risk ManagementCourse with your current carrier?If yes, please submit a copy of the certificate of completion with thisapplication. You must have completed the course within the past two yearsin order to receive the discount. If your course certificate has expired thanyou will need to successfully complete the course and submit a copy of thecertificate of completion before the discount will apply.If no, instructions on completing the course will be forwarded to you uponreceipt of your application.

b. No Consent OptionBy checking yes, I hereby authorize Hospitals Insurance Company, Inc. inexchange for a discount to my basic premium, to settle any and all claimsbrought against me without my consent.

c. New PhysicianAdditional discounts are available to physicians who join the VAP Programwithin 90 days of completing an approved Residency or Fellowship and areworking Full Time.Please check if you have completed an approved Residency or Fellowshipwithin the past 90 days.

Yes No


% % %

% % % %

%

(Please make additional copies of this page, if necessary)

1. Patient Name:

2. Age: 3. Gender: M F

4. Your relationship to patient (e.g. attending physician, primary surgeon, assistant surgeon, etc.):

5. Details of allegation(s):

6. Date of Incident:

7. Report Date:

8. Insurance carrier:

9. Other defendants:

10. Location of Incident:

11. Narrative description (include condition and diagnosis at time of incident, treatment dates anddescription of treatment rendered, condition of patient subsequent to treatment.

Date Paid: Amount Paid: Date Paid: Amount Paid: Date Paid: Amount Paid:

Disposition of claim: Precautionary/Incident report only Dropped by claimant Summary judgement in your favor Court trial in your favor Judgment against youSettlement Jury verdict against you Open


Section IX. Claim/Lawsuit Information

Question # Remarks

Section X. Additional Remarks


Specialty Classifications

PREMIUM CLASS 1 • Neurosurgery

PREMIUM CLASS 2 • General Surgery (including bariatric surgery)

PREMIUM CLASS 3 • Obstetrics and Gynecology

PREMIUM CLASS 4 • General Surgery (excluding bariatric surgery)

PREMIUM CLASS 5 • Orthopedic Surgery

PREMIUM CLASS 6 • Cardiothoracic Surgery• Vascular Surgery

PREMIUM CLASS 7 • Gynecology Only

(excluding prenatal care; obstetrical deliveries of any kind except for assistance at Cesarean sections; induced abortions except for those in the first trimester; ortreatment of spontaneous abortions except for those in the first trimester)

• Otolaryngology (including cosmetic plastic surgery)• Plastic and Reconstructive Surgery

PREMIUM CLASS 8 • Colon and Rectal Surgery and/or Proctology• Urology (including major surgery)

PREMIUM CLASS 9 • Emergency Medicine

PREMIUM CLASS 10 • Computerized Tomography• Diagnostic Radiology Only• Diagnostic Radiology and Radiation Oncology

PREMIUM CLASS 11 • Family/General Practice (including limited major surgery)

and/or Anesthesiology• Neurology and/or Psychiatry (including the supervision,

direction or performance of myelography and/orangiography

• Otolaryngology, (excluding cosmetic plastic surgery)

PREMIUM CLASS 13 • Internal Medicine (including cardiac catheterization)

PREMIUM CLASS 15 • Neurology (excluding the supervision, direction or

performance of myelography and/or angiography)

PREMIUM CLASS 16 • Dermatology (including dermabrasion, hair transplants,

micro-lipo injections, liposuction, face peels using phenol,Mohs microsurgery and all procedures listed in Class 22)

• Internal Medicine (excluding cardiac catheterization butincluding cardiology, gastroenterology, rheumatology,pulmonary disease, endocrinology and medical oncology)

• Radiation Oncology Only• Urology (including Minor surgery)

PREMIUM CLASS 17 • Ophthalmology (including major surgery)

PREMIUM CLASS 18 • Anesthesiology

PREMIUM CLASS 19 • Family/General Practice (excluding surgery)• Occupational Medicine (excluding surgery)

PREMIUM CLASS 20 • Pathology and/or Hematology

PREMIUM CLASS 21 • Pediatrics (excluding tonsillectomy and

adenoidectomy, other major surgery or general or spinalanesthesia)

• Ophthalmology (including minor procedures)

PREMIUM CLASS 22 • Dermatology excluding dermabrasion, hair transplants,

micro-lipo injections, liposuction, face peels using Phenol,Mohs microsurgery but including the use of laser, facepeels with agents other than Phenol, collagen injectionsand sclerotherapy

• Physical Medicine and Rehabilitation including pain medicine

PREMIUM CLASS 23 • Allergy (including pediatric allergy)• Dermatology excluding use of laser, dermabrasion, hair

transplants, micro-lipo injections, liposuction, face peelsusing Phenol, Mohs microsurgery, but including face peels with agents other than Phenol collagen injections and sclerotherapy

• Ophthalmology (excluding surgery)• Physical Medicine and Rehabilitation excluding pain

medicine• Preventive Medicine, Public Health• Psychiatry (excluding supervision, direction and/or

performance of myelography and/or angiography)

PREMIUM CLASS 54 • Oral Surgery (including dentists engaged in oral surgery or

operative dentistry on patients rendered unconsciousthrough the administration of any anesthesia or analgesia)

Note: Tonsillectomies, adenoidectomies, C sections, and abortions (other than the treatment of spontaneous abortions and those performed through 12 weeks) are considered major surgery. The Family/General Practice classification is not available to physicians that perform (1) open orthopedic procedures or elective intra-abdominal surgery including hysterectomies, cholecystectomies, or gastrectomies.


Release and Authorization

I hereby authorize HIC to obtain full information from any insurer or from any person, health care facility, organization or governmental agency with respect to any claim, suit or incident pertaining to professional acts or omissions asserted against me. I recognize that I may be required to furnish as part of my application a copy of my National Practitioner Date Bank report. I expressly release and discharge any insurers, persons, organizations or agencies, including but not limited to HIC, from liability for providing or receiving such information. I further authorize that a photocopy of this release may be accepted with the same authority as the original.

I appoint HIC (and/or such attorneys or representatives as it may appoint) to act in my behalf as attorney in fact in exercising any or all of my rights arising under or in relation to the policies of insurance, which are, have been, or will be in force for my benefit, including but not limited to the following: notification of claims; presentation of information and documentation; demand, receipt and remittance of payments and any other monies representing the liabilities of insurers under policies covering me, making of financial arrangements to facilitate the payment of claims and any other actions that HIC may deem necessary or useful. This appointment shall apply in respect of all insurance policies arranged for me by HIC whether they be past, present or future.

I hereby attest that the statements made in this application are true, complete and accurate and may be relied upon by HIC for the purpose of issuing coverage.

NOTE: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT ACT, WHICH IS A CRIME, AND WILL INVALIDATE YOUR INSURANCE COVERAGE.

Electronic Signature of Applicant (please print and sign if you elect not to use electronic signature)

Full Name (Please Print)

Date


VAPSec.18.App.(5/2020)

Physician and Surgeons Section 18 Excess Professional Liability Insurance Application

Section 18 excess professional liability insurance is available at no charge to Voluntary Attending Physicians (VAP) that have primary coverage through Hospitals Insurance Company, Inc. (HIC). Section 18 excess coverage is issued on an Occurrence form with Limits of Liability of $1,000,000 each medical incident and $3,000,000 annual aggregate. Eligibility requirements include a) a valid New York State medical license; b) an individual primary professional liability policy with limits of $1.3 million/$3.9 million; c) an affiliation with a New York State general hospital and d)completion of a qualified risk management program.

Title (MD,DO,DMD):

I authorize release and exchange of information, involving but not limited to claim matters, between my professional society or association, previous insurance carrier, hospital or clinic and Hospitals Insurance Company, Inc.

Signature (please print out and sign if you elect not to use electronic signature)

Date (mm/dd/yyyy)

Name (please print)

Please return application by Email, Fax or mail: Email: [email protected]

Fax: 212.702.6359 Mail: Underwriting and Physician Services

Healthcare Risk Advisors 111 West 33rd Street, 8th Fl. New York, NY 10120

NOTE: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY 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 WILL INVALIDATE YOUR INSURANCE COVERAGE.

Name (First,MI,Last): NYS License No.: Requested Effective Date (mm/dd/yyyy): Name of Previous Section 18 Excess Insurance Carrier and Dates of Coverage:

Note: Generally, physicians and oral surgeons are eligible for the Section 18 Liability Program if they are in the Section 18 Pool for the policy year ending June 30 of the current year. The primary hospital may certify additional physicians and oral surgeons up to its proportionate share of participants in the Section 18 Pool as of June 30 of the current year. Applicants new to Section 18 will be waitlisted until the hospital’s has completed its review in January of the upcoming year.


HIPAA BUSINESS ASSOCIATE AGREEMENT

This HIPAA Business Agreement (HIPAA Agreement), effective as of is made by and between (“Covered Entity”), Hospitals Insurance Company and Healthcare Risk Advisors (HRA) Service Corporation (each, separately, a “Business Associate” and individually bound by this Agreement) for the purpose of compliance with the Health Insurance Portability and Accountability Act and its implementing administrative simplification regulations (45 CFR 160-164) (HIPAA) and Subtitle D of the Health Information Technology for Economic and Clinical Health Act (HITECH). This HIPAA Agreement hereby amends and is incorporated into any underlying agreement between Covered Entity and a Business Associate; to the extent that the provisions of this HIPAA Agreement conflict with those of an underlying agreement, the provisions of this HIPAA Agreement shall control. Terms used but not otherwise defined herein shall have the same meaning as those terms defined in 45 CFR 160.103 and 164.501. If, in the provision of services to Covered Entity, representatives of a Business Associate may receive or have access to Protected Health Information (PHI) that is created and/or maintained by Covered Entity, the Business Associate shall be bound to the following terms:

1. Permitted Uses and Disclosures. Business Associate may use and disclose PHI in the course of

performing services for or on behalf of Covered Entity or as required or permitted by law, regulation, regulatory agency or by any accrediting body to whom Covered Entity or a Business Associate may be required to disclose such PHI; a Business Associate may also use PHI for the proper management and administration, or to carry out the legal responsibilities of, Business Associate.

In addition to using the Protected Health Information to perform the services set forth above, we may: a. Aggregate the Protected Health Information in our possession with the Protected Health Information

of other covered entities that we have in our possession through our capacity as a business associate to said other covered entities, provided that the purpose of such aggregation is to provide you with date analyses relating to your healthcare operations. Under no circumstances may we disclose Protected Health Information of one covered entity as defined by 45 C.F.R. Parts 160 and 164 to another covered entity absent your express written authorization; and

b. De-identify any and all Protected Health Information provided that the de-identification conforms to the requirements of 45 C.F.R. Section 164.514(b), and further provided that you are sent the documentation required by 45 C.F.R. Section 164.15(b), which shall be in the form of a written assurance from us. Pursuant to 45 C.F.R. 164.502(d)(2), de-identified information does not constitute Protected Health Information and is not subject to the terms of this agreement.

2. Business Associate’s Obligations. Each Business Associate shall:

a. ensure that its agents and subcontractors to whom it may provide PHI agree to the same terms and conditions through a written contractual arrangement that complies with 45 CFR § 164.314;

b. implement appropriate and reasonable safeguards to prevent use or disclosure of PHI other than as permitted herein, including those safeguards required pursuant to 45 CFR § 164.308, 164.310, 164.312, 164.314, and 164.316, in the same manner that those requirements apply to Covered Entity pursuant to 45 CFR § 164.504, and report to Covered Entity any use or disclosure of PHI not provided for by this Agreement;

c. make available, to the Secretary of Health and Human Services, Business Associate’s internal practices, books and records relating to the use or disclosure of PHI for purposes of determining Covered Entity’s compliance with HIPAA; subject to any attorney-client or other privileges;

d. report to the Covered Entity, and mitigate to the extent practicable, any harmful effect that is known

to Business Associate of, uses or disclosures of PHI of which Business Associate becomes aware that do not comply with the terms herein, including breaches of unsecured PHI as required by

45 CFR § 164.410, and any Security Incident of which it becomes aware; e. if applicable, to the extent that Covered Entity and Business Associate agree in writing that Business

Associate shall maintain PHI as part of a Designated Record Set, upon Covered Entity’s request,provide paper or electronic access and make amendments to such PHI, in order to meet therequirements under HIPAA, and if an individual requests an electronic copy of the information fromCovered Entity, Business Associate must provide Covered Entity with the information requested inthe electronic form and format requested by the individual and/or Covered Entity if it is readilyproducible in such form and format; or if not, in a readable electronic form and format as requestedby Covered Entity; and if Business Associate receives a request for amendment to PHI directly froman individual, Business Associate shall notify Covered Entity upon receipt of such request;

f. document such uses and disclosures of PHI and, upon Covered Entity’s request, provide suchinformation as would be required for Covered Entity to account for disclosures of PHI as requiredunder HIPAA;

g. when Business Associate ceases to perform services for or on behalf of Covered Entity, BusinessAssociate will destroy all PHI received or continue to abide by the terms set forth herein withrespect to such PHI; and,

h. following a discovery of a breach of Unsecured Protected Health Information, as defined in HITECH,notify Covered Entity of such breach within thirty (30) days of the discovery of the breach.

3. Term and Termination. The term of this HIPAA Agreement shall be effective as of the date set forthabove and shall terminate when Business Associate ceases to perform services for Covered Entity,except as provided in 2(g) above. Covered Entity may terminate this HIPAA Agreement if BusinessAssociate fails to cure or take substantial steps to cure a material breach of this HIPAA Agreementwithin thirty (30) days after receiving written notice of such material breach from Covered Entity.

4. Agreement. This Agreement constitutes the entire agreement between the parties. This Agreementmay be amended only in writing signed by Covered Entity and the Business Associate to whom theamendment pertains. The parties agree to take such action to amend this Agreement as is necessaryto comply with the requirements of HIPAA and HITECH. This Agreement and the rights and obligationsof the parties hereunder shall in all respects be governed by, and construed in accordance with, the lawsof the State of New York, including all matters of construction, validity and performance.

BUSINESS ASSOCIATE COVERED ENTITY

By:

By:

BUSINESS ASSOCIATE

By:

Title: Senior Vice President Claim and Litigation Services

Title: Vice President Underwriting and Physician Services

(Please print out and sign if you elect not to use electronic signature)

Title:

CONSENT FOR USE OF ELECTRONIC DOCUMENTS AND SIGNATURE

If you want the option of sending, receiving and executing your insurance documents by e-mail and/or

other electronic means, New York State and Federal law require that certain safeguards be implemented

to ensure that consumers like you have the ability to receive such documents and are fully aware of the

consequences of agreeing to receive documents electronically. Both state and federal law require your

consent to use e-mail and electronic versions of policies, contracts, information, disclosures, and other

documents and records (“Electronic Documents”).

Because your consent for use of Electronic Documents and signature is completely voluntary, please note

the following:

1. Right to Receive Paper Document. You have the right to have any document or record provided in

paper/hardcopy form. If you want a paper form or hardcopy of any documents sent to you by e-mail,

send your request to us at the mail or e-mail provided. Paper copies will be provided at no additional

charge.

2. Right to Withdraw Consent at Any Time. You have the right to withdraw your consent to receive

electronic documents by e-mail. Please note, the legal validity and enforceability of the electronic

documents, signatures and deliveries used prior to the withdrawal of your consent will not be

affected.

3. Notify the Company of Changes to Your E-Mail Address. Because you will receive all Electronic

Documents via e-mail, you should keep us informed of any changes to your e-mail or electronic

address. Please contact us as promptly as possible by mail or e-mail regarding any changes to your e-

mail or electronic address. Moreover, because you will be receiving the Electronic Documents by e-

mail, please take additional measures to ensure that your e-mail is appropriately password protected

and secured to prevent unauthorized access to your documents and personal information. Please

contact your e-mail service provider for additional information on how to appropriately protect your

electronic communications.

4. Your Ability to Access Disclosures. By completing and executing this consent form, you

acknowledge that you can access (open and read) and retain (save) the Electronic Documents in MS

Word (or its equivalent) or PDF file format.

By completing and executing and/or e-mailing this consent form to Hospitals Insurance Company, Inc.

(“Company”), you are providing consent to the use of Electronic Documents and signature in your

communication with the Company. Specifically, you are acknowledging receipt of this consent form,

notice of rights, and consenting to the use of Electronic Documents, e-mail delivery of documents, and

electronic signatures in any communication, transactions or the same involving you, the Company, and

any of the Company’s authorized personnel.

2

Please select the appropriate designation below:

I CONSENT to receive my documents and communications through electronic means.

Date Signature (Please print out and sign if you elect not to use electronic signature)

Email address

Please return this consent form by email, fax or mail:

Email: [email protected]: 212.702.6359

Mail: Underwriting & Physician Services

Healthcare Risk Advisors

111 West 33rd Street

New York, New York 10120

I DECLINE to receive my documents and communication through electronic means.