AXIS HEALTHCARE PROFESSIONAL LIABILITY INSURANCE POLICY HOSPITAL APPLICATION (for surplus lines coverage) AXIS SURPLUS INSURANCE COMPANY Producer Agency Name: Producer Name: Telephone: E-Mail: Applicant Named Insured: County: Address: City/State/Zip: CEO: Risk Manager: Website: www. Authorized representative for insurance matters: Telephone: Number of years the Applicant has been in operation: Number of years the Applicant has been under present ownership: Other Entities List all owned (50% or more) entities to be considered as a Named Insured, or attach a separate list: Name Type/Purpose of Facility Retroactive Date Facility Information Type (check all that apply) Ownership and Control Tax Status Governmental For Profit Children’s Hospital Clinic Individual Not for Profit Convalescent or Nursing Home Partnership Medicare Approved General Acute Care Hospital Corporation Hospice Psychiatric Hospital Research Hospital Surgical Center Teaching Hospital The facility is (check all that apply): Accredited by AOA* Member of American Hospital Association Medicare Approved Accredited by JCAHO* Member of State Hospital Association Other (describe below): *Date of last survey: *Accreditation Period: Details of Requested Coverage Requested Effective Date: Expiration Date: Date Quote is Needed: Requested Limits $ $ Professional Liability Claims Made Retroactive Date: per claim aggregate Occurrence Coverage $ $ General Liability Claims Made Retroactive Date: per claim aggregate Employee Benefits Admin. Liability Claims Made Retroactive Date: $ $ (EBL) Total number of employees: per claim aggregate $ $ Excess Liability Claims Made Retroactive Date: per claim aggregate $ $ Umbrella Liability Claims Made Retroactive Date: per claim aggregate
AXIS HEALTHCARE PROFESSIONAL LIABILITY INSURANCE POLICY HOSPITAL APPLICATION (for surplus lines coverage) AXIS SURPLUS INSURANCE COMPANY Producer Agency Name: Producer Name: Telephone: E-Mail: Applicant Named Insured: County: Address: City/State/Zip: CEO: Risk Manager: Website: www. Authorized representative for insurance matters: Telephone: Number of years the Applicant has been in operation: Number of years the Applicant has been under present ownership: Other Entities List all owned (50% or more) entities to be considered as a Named Insured, or attach a separate list: Name Type/Purpose of Facility Retroactive Date Facility Information Type (check all that apply) Ownership and Control Tax Status Children’s Hospital Governmental For Profit Clinic Individual Not for Profit Convalescent or Nursing Home Partnership Medicare Approved General Acute Care Hospital Corporation Hospice Psychiatric Hospital Research Hospital Surgical Center Teaching Hospital The facility is (check all that apply): Accredited by AOA* Member of American Hospital Association Medicare Approved Accredited by JCAHO* Member of State Hospital Association Other (describe below): *Date of last survey: *Accreditation Period: Details of Requested Coverage Requested Effective Date: Expiration Date: Date Quote is Needed: Requested Limits Professional Liability $ per claim $ aggregate Claims Made Retroactive Date: General Liability $ per claim $ aggregate Occurrence Coverage Claims Made Retroactive Date: Employee Benefits Admin. Liability (EBL) $ per claim $ aggregate Claims Made Retroactive Date: Total number of employees: Excess Liability $ per claim $ aggregate Claims Made Retroactive Date: Umbrella Liability $ per claim $ aggregate Claims Made Retroactive Date:
HOSPITAL-APP.docx