Confirm Quote
Consents and Authorizations
Online Quote – Health Allied
Resolve General Agency LLC / Puerto Rico Medical Defense Insurance Company (PRMD)
IMPORTANT NOTICE
You (hereinafter, “Applicant”) are applying for professional liability insurance for Aliados de la Salud under the “claims-made” or “Claims Made & Reported“which, if approved, would be issued by Puerto Rico Medical Defense Insurance Company (hereinafter, the “Company”).
Please read this application carefully and fill in all the required information. Eligibility determination and coverage approval will be based on the information provided and any additional documentation that may be required.
The Company may request additional documentation to complete the underwriting process; in such cases, you will be notified through your authorized insurance representative.
Under a policy of the type Claims Made & Reported, coverage applies only to claims arising from medical incidents that occurred on or after the Retroactive Date specified in the policy, provided that such claims are:
- First raised against the insured during the policy term; and
- Reported in writing to the Company in accordance with the notification provisions set forth in the policy.
Coverage does not apply to medical incidents that occurred prior to the Retroactive Date, unless expressly provided for in an endorsement issued by the Company.
INFORMATION ABOUT “STEP-UP” PREMIUMS
During the first few years of a Claims-Made & Reported policy, premiums may be lower and gradually increase until they reach their mature level. These adjustments may occur regardless of general changes in rates or risk classifications.
APPLICANT CONFIRMATIONS
By completing this application, the Applicant declares and certifies that:
- All information provided in this application and any supporting documentation is true, accurate, and complete to the best of the Applicant's knowledge and belief.
- The Applicant understands that this application and any supporting documentation submitted at the Company's request will be relied upon in evaluating eligibility for coverage and the potential issuance of an insurance policy.
- The Applicant agrees to notify Resolve General Agency, LLC of any material changes to the information provided prior to the issuance of the policy.
- The Applicant acknowledges that completion of this application or quote request does not guarantee acceptance, approval, or issuance of coverage.
CONSENT & AUTHORIZATIONS
The Applicant authorizes the use of electronic and physical means to:
- Receive communications related to the quote or application;
- Exchange documents and forms;
- Confirm acceptance of applicable terms, conditions, and consents;
- Receive notifications related to the evaluation and issuance process.
- Neither the Company nor its authorized representatives will use the Applicant's personal information for any purpose other than evaluating, underwriting, issuing, administering, or servicing the requested insurance coverage.
- The Applicant acknowledges that electronic communications shall have the same legal validity and effect as those transmitted by postal mail or other physical means.
FRAUD NOTICE
Article 27.320 of the Puerto Rico Insurance Code
“Any person who knowingly and with the intent to defraud provides false information in an insurance application, or who submits, assists in submitting, or causes the submission of a fraudulent claim for payment of a loss or other benefit, or submits more than one claim for the same damage or loss, shall be guilty of a felony and, upon conviction, shall be punished for each violation by a fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or imprisonment for a fixed term of three (3) years, or both penalties. If aggravating circumstances are present, the fixed term may be increased to a maximum of five (5) years; if mitigating circumstances are present, it may be reduced to a minimum of two (2) years.”
Personal Information
- Applicant's name:
- Date of Birth:
- Physical Address: ,
- Mailing Address:
- Email:
- Phone Number:
- Places where he works:
- Select your specialty (the liability limit will be $100,000 per incident / $300,000 annual aggregate).
- Please include your professional license number for your specialty:
- Expiration date of professional license
Questions
1. Do you perform cosmetic procedures?
2. Do you work in the Emergency Room / ER?
3. What is the primary group of patients/clients you serve?
4. Have you been directly or indirectly involved in any medical malpractice claim, incident, lawsuit, situation, investigation, or circumstance that could result in a claim related to your professional services, including incidents reported to previous insurers?
5. Have you been the subject of any investigation, disciplinary action, suspension, restriction, revocation, or review related to your professional license, clinical privileges, or professional practice by an examining board, regulatory agency, government entity, or professional association?
6. Have you been the subject of any investigation, audit, sanction, or proceeding related to HIPAA, Medicare, Medicaid, the U.S. Department of Health and Human Services (HHS), or any government, regulatory, or administrative entity related to your professional practice?
7. Has any insurance company denied, canceled, declined to renew, restricted, or issued coverage subject to special conditions related to professional liability?
8. Have you ever been charged with, convicted of, found guilty of, or pleaded nolo contendere to any criminal offense, excluding minor traffic violations?
9. Has any hospital, healthcare facility, managed care organization, or similar entity restricted, suspended, reduced, revoked, or placed on probation your clinical or professional privileges?
10. Have you ever been subject to suspension, revocation, restriction, probation, censure, or any other disciplinary action related to a professional membership or organization?
