Application for Naturopathic Doctor Coverage

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Instructions

Read and answer ALL questions completely and accurately, leaving no blanks (use “N/A” if Not Applicable), as incomplete or inaccurate responses can affect coverage eligibility.
If you need more space for a response, continue on a separate sheet of paper and indicate the question #.
The application MUST be signed and dated by the applicant.
If your most recent policy is “claims-made” and you desire to continue coverage back to your “retroactive date,” proof of continuous claims-made coverage must be submitted with this application (Current Declarations Page or Certificate of Insurance).

NOTICE: If CLAIMS-MADE COVERAGE IS CHOSEN, coverage applies only to those claims arising from naturopathic incidents which occur on or after the retroactive date stated in the policy Declarations. In addition, the claim must be first made against you and reported in writing to the company during the policy period or any applicable extended reporting period. Please review the policy carefully and discuss the policy with your insurance representative.

I. Practice Information

Applicant Full Legal Name (first, middle initial, last): Dr.(Required)

First Middle initial Last

Referred by

Primary Practice Address(Required)

Street City State Zip

Mailing Address

If same as above, check here

Mailing Address (If Different)(Required)

Street City State Zip

Mobile Phone(Required)

Office Phone

Fax

Email Address(Required)

Secondary Practice?

Yes

Secondary Practice Address

Street City State Zip

Do you own the Practice in which you work?(Required)

Yes

If Yes, to add the entity as an Additional Insured free of charge, provide Legal Entity name here

If you are an Employee or Independent Contractor, list clinic owner’s name

II. Additional Providers

List any additional healthcare providers (i.e. MD, DO, PA, NP, DC, LAc, LMT, etc.) working in your practice:

Are there any additional healthcare providers (i.e. ND/NMD, MD, DO, PA, NP, DC, LAc, LMT, etc.) working in your practice?(Required)

Yes

Add Provider?

Add Provider

Name, Title

Is currently insured?

Yes

Add Provider?

Add Provider

Name, Title

Is currently insured?

Yes

List any others on a separate sheet

Please provide PDF, TXT, DOC or DOCX document with other providers.

Drop files here or

Accepted file types: pdf, txt, doc, docx, Max. file size: 32 MB, Max. files: 1.

(List any others on a separate sheet)

III. Requested Coverage

Do you currently have active Malpractice Insurance coverage?(Required)

Yes

If your current policy is Claims-Made, please list your “Retroactive Date”

MM slash DD slash YYYY

Please provide an explanation(Required)

Have you had any Malpractice Insurance coverage within the past 5 years?(Required)

Yes

Add Policy?

Add Policy

Policy Period(Required)

Insurer(Required)

Limits(Required)

Annual Premium(Required)

Claims-Made / Occurrence(Required)

Add Policy?

Add Policy

Policy Period(Required)

Insurer(Required)

Limits(Required)

Annual Premium(Required)

Claims-Made / Occurrence(Required)

Add Policy?

Add Policy

Policy Period(Required)

Insurer(Required)

Limits(Required)

Annual Premium(Required)

Claims-Made / Occurrence(Required)

Add Policy?

Add Policy

Policy Period

Insurer(Required)

Limits(Required)

Annual Premium(Required)

Claims-Made / Occurrence(Required)

Requested Policy Activation Date (On or after application date)(Required)

MM slash DD slash YYYY

Requested Coverage Type(Required)

Claims-Made

Occurrence

Requested Limits of Liability (Check one)(Required)

$1,000,000 / $3,000,000

$500,000 / $1,000,000

$250,000 / $750,000

$200,000 / $600,000

$100,000 / $300,000

Other

Are you requesting an additional insured be added to your policy at an additional charge?(Required)

Yes

Legal business entity name(Required)

Affiliation(Required)

Requested Supplemental Defense Limits (Check one)(Required)

$10,000 (Included)

$50,000 (Additional Fee)

$100,000 (Additional Fee)

IV. Applicant Practice Profile

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Current or projected number of patients you treat, on average, per week.

Current or projected number of patients you treat, on average, per week.(Required)

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Number of hours you spend in patient care, on average, per week.

(Patient care includes consultation with patient, examination, treatment, documentation of care, lab time, etc.)

Number of hours you spend in patient care, on average, per week.(Required)

(Patient care includes consultation with patient, examination, treatment, documentation of care, lab time, etc.)

Please select the services below that you (or someone under your direct supervision) provide in your practice.
If you provide other services NOT listed, list those in the Other Services/Specify box so that underwriting can review and confirm whether coverage will apply.

CLASS 1 SERVICES

Acupuncture/Oriental Medicine

In-Home Healthcare

Physiotherapy

Diet and Lifestyle Counseling

Naturopathic Physical Medicine

Shockwave Therapy

Homeopathy

Nutritional Medicine

Telemedicine

Western Herbal Medicine

CLASS 2 SERVICES

Injection Therapy (Subcutaneous, Intramuscular)

Medical Cannabis

Weight Loss Care (Prescription Medicine)

Laser/Light Therapy

Prescription Medicine (RX Only)

CLASS 3 SERVICES

Aesthetic Medicine (Botox, Fillers)

In-Office Compounding

Prescriptions (Controlled Substances)

Cryotherapy

IV Therapy

Regenerative Injection Therapy (Prolo, PRP, MSCs)

Gynecology

Minor Surgery

Weight Loss Care (Controlled Substances)

Hormone Replacement Therapy

Ozone Therapy

OTHER SERVICES / SPECIFY

(List services provided which are not indicated above to confirm coverage)

V. Licensure / Education

Naturopathic College Attended(Required)

Graduation Date(Required)

MM slash DD slash YYYY

License Information: First date you were licensed to practice(Required)

MM slash DD slash YYYY

List all states in which you have carried a license.

Add License?

Add License

Naturopathic License Number

State

Date First Licensed

MM slash DD slash YYYY

Add License?

Add License

Naturopathic License Number

State

Date First Licensed

MM slash DD slash YYYY

Add License?

Add License

Naturopathic License Number

State

Date First Licensed

MM slash DD slash YYYY

Do you carry any other Professional Licenses? (i.e. Acupuncture, Chiropractic, Massage, etc.)(Required)

Yes

If Yes, please specify licenses

VI. Risk Management

Have you taken a continuing education course that included patient safety or risk management topics in the last two years?(Required)

Yes

Is patient progress documented each visit?(Required)

Yes

How are patient records kept?(Required)

handwritten

travel card

dictated

software

Software name(Required)

If necessary, would you refer to other healthcare practitioners, those patients who require additional clinical assessment, diagnosis, and/or treatment outside your scope of practice?(Required)

Yes

Do you utilize an informed consent form?(Required)

Yes

Do you require signed release forms for the release of medical records?(Required)

Yes

Do you utilize patient educational materials in the office?(Required)

Yes

Are you an active (dues paying) member of any naturopathic associations?(Required)

Yes

If Yes, please specify

Are you a member of any Practice Management, Coaching, or Franchise Company?(Required)

Yes

If Yes, please specify

VII. Claims History

Have you (or the corporation you own) ever been the subject of an investigation, complaint, reprimand, or disciplinary action, by your State Board, Governmental Agency, or an Insurance Company?(Required)

Yes

Have you ever had your naturopathic license suspended, revoked, voluntarily surrendered, or been placed on probation in any state?(Required)

Yes

Have you ever been denied, cancelled (other than for non-payment), refused renewal, or accepted only on special terms for professional liability insurance coverage?(Required)

Yes

Have you ever been accused or convicted of any crime, other than a minor traffic violation, in any State or Country?(Required)

Yes

Have you ever been treated, or sought treatment, for alcoholism, drug abuse, or mental illness?(Required)

Yes

Do you (or the corporation you own) have any current or prior claims?(Required)

If Yes, you must submit a Loss Runs Report from the carrier that covered you for the claim.

Yes

Are you aware of any circumstance, accident or loss, including those arising from your billing practices, that has not been reported to your insurance carrier, but which may result in a claim or lawsuit being made against you, your predecessors in business, or against any past or present partner(s)?(Required)

Yes

* If you answered YES to any of the above, you will need to provide a full written explanation and complete additional forms.

Full written explanation(Required)

Please provide a full written explanation for each of questions you answered YES in the section VII above.

Drop files here or

Accepted file types: pdf, txt, doc, docx, Max. file size: 32 MB, Max. files: 7.

VIII. Applicant Declarations And Signatures

I, the applicant, declare that I have signed or typed my name where indicted below, and that the statements set forth herein are true. I agree that if the information supplied on this application changes between the date of this application and the effective date of the insurance, I will immediately notify the company of such changes, and the company may withdraw or modify any outstanding quotations, authorization or agreement to bind the insurance.

I understand that by signing this application, neither I nor the company are required to complete and bind the insurance, but it is agreed that this application shall be the basis of the contract should a policy be issued. All written statements and materials furnished to the company in conjunction with the application are hereby incorporated by reference into the application and made a part hereof.

The earliest effective date for which a policy may be issued is the date this application is received in our office.

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Applicant Signature

Applicant Signature(Required)

Date(Required)

MM slash DD slash YYYY

Applicant’s Name(Required)

Title:(Required)