AAHP-RRG Professional Liability Questionnaire (PLQ)

The below questionnaire will be used in an underwriting process to determine university affiliated academic healthcare providers’ eligibility for professional liability coverage afforded by the Florida Affiliated Academic Healthcare Providers – A Reciprocal Risk Retention Group (AAHP-RRG). This coverage is limited only to those affiliated academic healthcare providers who are eligible by her/his SUPPORT of the healthcare missions of the University of Florida (UF), Florida State University (FSU), University of Central Florida (UCF), Florida Atlantic University (FAU), and Florida International University (FIU).

AAHP-RRG, created by the Florida Board of Governors self-insurance programs serving UF, FSU, UCF, FAU and FIU, provides CLAIMS-MADE professional liability protection of TWO HUNDRED AND FIFTY THOUSAND ($250,000.00) per occurrence (total claims or judgment arising out of the same event) and SEVEN HUNDRED AND FIFTY THOUSAND ($750,000.00) in the aggregate during the policy period for the above referenced healthcare providers who meet rigorous underwriting criteria. This coverage is intended to help affiliated academic healthcare providers demonstrate financial responsibility under Florida Statute 459.0085 and to remain in compliance with hospital bylaws and requirements.

NOTICE: The AAHP-RRG policy is issued by a risk retention group. This risk retention group may not be subject to all the insurance laws and regulations of your State. State insolvency guaranty funds are not available for this risk retention group.

Once starting the below PLQ, you must fully complete and submit the questionnaire; you cannot save and return at a later time to finish and submit. As such, we recommend you review a hard copy of the questionnaire (provided HERE) to ensure you have all needed information before starting.

Please allow up to 30 business days for processing.

AAHP-RRG PROFESSIONAL LIABILITY COVERAGE QUESTIONNAIRE

Requested Policy Start Date *

To allow time for underwriting and processing, the start date must be at least 30 days after the date this questionnaire is submitted to AAHP-RRG Insurance Services.

Select Your University Affiliation *

• University of Florida
• Florida State University
• University of Central Florida
• Florida Atlantic University
• Florida International University

List your University Affiliation Contact Name, Title, and Email Address or Phone # *

Your University contact who can confirm your affiliate status and referral for AAGH-RRG membership consideration.

GENERAL PROVIDER INFORMATION

Name *

First

Last

Preferred Email *

Email

Confirm Email

Cell Phone *

Other Phone

Personal Mailing Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Degree *— Select Choice —Doctor of Medicine (MD)Doctor of Osteopathic Medicine (DO)Bachelor of Medicine, Bachelor of Surgery (MBBS)Bachelor of Science in Nursing (BSN)Physician Assistant (PA) CertificationNurse Practitioner (NP) CertificationDoctor of Dental Medicine (DMD)Doctor of Dental Surgery (DDS)Doctor of Pharmacy (PharmD)Doctor of Veterinary Medicine (DVM)Doctor of Podiatric Medicine (DPM)Doctor of Optometry (OD)Doctor of Chiropractic (DC)Other

Florida Board License # (Please include the prefix. E.g., ME, OD, PA) *

Select the county where the majority of your patient care will be provided. *

• Dade & Broward
• Palm Beach
• Martin & St. Lucie
• Clay, Duval, & St. Johns
• Remainder of State
• Out of Florida

List the names and address of the facilities where you will be providing clinical services. *

SPECIALTY INFORMATION

Surgery Class *— Select Choice —NoneMinorMajor

NONE: Includes incision of boils & superficial fascia, suturing of minor lacerations and removal of superficial skin lesions by other than surgical excision. MINOR: Includes operations not considered to involve a risk to life, circumcisions, & non-major OB procedures. Excludes all surgeries and procedures that meet the criteria of major surgery. MAJOR: Includes removal of tumors, open bone fractures, amputations, removal of any gland or organ, plastic surgery, tonsillectomy, adenoidectomy, caesarean section, and any operation in or upon any body cavity, including but not limited to cranium, thorax, abdomen or pelvis or any other operation that because of the condition of the patient or the length or circumstances of the operation presents a distinct hazard to life.

located is are

Medical or Surgical Specialty *— Select Choice —AnesthesiologyEmergency MedicineFamily MedicineInternal MedicineNeurologyNeurological SurgeryObstetrics and GynecologyOphthalmologyOrthopedicOtolaryngology (ENT)PathologyPediatricsPodiatryPsychiatryPulmonologyRadiation TherapyRadiologySurgeryOther

NICA: All prospective and active AAHP-RRG members who practice obstetrics or perform obstetrical services on a full or part-time basis will be required to provide proof of NICA participation with this questionnaire submission and on an annual basis thereafter. https://www.nica.com/medical-providers/

If Other selected above, please define:

Medical or Surgical Sub-Specialty *— Select Choice —AbdominalAerospace MedicineAllergy and ImmunologyBariatricBroncho-EsophagologyCardiacCardiovascular DiseaseCritical careColon & RectalDermatologyDiabetesEndocrinologyFamily Medicine – Includes DeliveriesFamily Medicine – Excludes DeliveriesForensic MedicineGastroenterologyGeneralGeneticsGeriatricsGynecologyHematologyHandHand & NeckHematologyHospice/Palliative CareHospitalistInfectious DiseaseIntensive CareLaryngologyNeonatologyNephrologyNuclear MedicineNeurologyNutritionObstetrics – Includes DeliveriesObstetrics – Excludes DeliveriesOccupational MedOncology/Neoplastic DiseasesOphthalmologyOral SurgeryOrtho: Excludes SpineOrtho: Includes SpineOncologyOtologyOtorhinolaryngologyOtorhinolaryn/PlasticPain ManagementPathologyPediatricsPharmacology, Clin.Physiatry/Physical Med & RehabPlastic SurgeryPodiatryPreventative MedicinePsychiatryPsychosomatic MedPulmonologyRadiologyRheumatologyRhinologySclerotherapySports MedicineOtherN/A

If Other selected above, please define:

Medical Techniques or Procedures *— Select Choice —Acupuncture (other than acupuncture anesthesia)AngiographyArteriographyCatheterization/Arterial, cardiac or diagnostic (see exclusion 1 below)ColonoscopyDiscogramEndoscopic Retrograde CholangiopancreatographyElectroconvulsive TherapyLaparoscopyLasersLymphangiographyMyleographyNeedle Biopsy (see exclusion 2 below)PhlebographyPneumatic or Mechanical Esophageal Dilation (see exclusion 3 below)PneumoencephalographyRadiation TherapyRadiopaque Dye Injections into blood vessels, lymphatics, sinus tracts or fistulae (see exclusion 4 below)OtherN/A

Exclusion 1: Does not include occasional emergency insertion of pulmonary wedge pressure recording or temporary pacemaker, urethral caths, or umbilical cord cath for diagnostic purpose or for monitoring blood gases in newborns on oxygen; Exclusion 2: Does not include fine needle aspiration and does not include liver, kidney or bone marrow biopsy; Exclusion 3: Does not include dilation with bougie or olive Exclusion; 4: Not applicable to Radiologists

If Other selected above, please define:

ADDITIONAL UNDERWRITING INFORMATION

1. Will you be providing on-site clinical services outside the state of Florida? *

• YES
• NO

If YES selected above, list the states where additional services will be provided, and the % of time performing out of state services (>/-=50% or <50%)

2. Will you be providing telemedicine? (Telemedicine definition: the practice of health care delivery by a practitioner who is located at a site other than the site where the recipient is located for the purposes of evaluation diagnosis and or treatment in parentheses.) *

• YES
• NO

If YES selected above, list the states where additional services will be provided, and the % of time performing out of state services (>/-=50% or <50%) (copy)

3. Has your license to practice medicine or your permit to prescribe drugs ever been denied, revoked, suspended, placed on probation, subjected to reprimand, voluntary surrendered or any other way limited, or has it been or is it currently under investigation? If YES, please attach a detailed written explanation. *— Select Choice —YESNO

4. Have you ever been or are you currently under a consent order? If YES, attach a copy of the consent order and its termination if applicable. *— Select Choice —YESNO

5. Have your hospital staff privileges ever been denied, suspended, revoked, placed on probation, voluntarily surrendered or in any other way restricted, or have they been or are they currently under investigation? If YES, please attach a detailed written explanation. *— Select Choice —YESNO

6. Has any insurance company ever cancelled, declined to issue or refuse to renew your professional liability insurance, or offered such insurance only on special terms, or have you been notified of such intent? If YES, please attach a copy of the cancellation notice or letter if applicable. *— Select Choice —YESNO

7. Have any claims been asserted or civil actions filed against you alleging errors or omissions, or against your employer or any other entity responsible for or alleged to be responsible for your patient care activities, or have you been notified that such an action will be filed? If YES, please complete a Claim Supplement form for each claim and civil action. *— Select Choice —YESNO

8. Have any judgments been made against you, or any out-of-court settlements been made on your behalf, from an event alleging medical errors or omissions that were not addressed in #7 of? If YES, please fully complete a Claim Supplement form for each claim. *— Select Choice —YESNO

9. Have you ever been convicted of a criminal offense or are or are you under investigation for criminal offense? If YES, please attach a detailed written explanation. *— Select Choice —YESNO

10. Have you been treated for alcoholism or drug addiction within the last five years? If YES, please attach a detailed written explanation including dates and locations of all treatments and the names of your supervising and monitoring physicians. *— Select Choice —YESNO

11. Have you incurred or become aware of having a condition that impairs your ability to practice your specialty? If YES, please attach a detailed written explanation. *— Select Choice —YESNO

EVENT REPORTING REQUIREMENTS

When to Contact the AAHP-RRG:

As a covered FL AAHP provider, it is essential and expected that you notify us immediately if:  You were involved, or alleged to have been involved, in an event while delivering healthcare services that may have caused or resulted in an injury (real or perceived) to a patient;  You received a complaint, legal notice, or licensure investigation notice related to your delivery of healthcare services;  You received a subpoena for deposition or medical records.

How to Contact the AAHP-RRG:

You must notify us in writing by one of two options: 1) Complete an Event Notice and mail to the AAH-RRG by mail, or 2) Report the event online at: SIPSAAHP.org. If questions, call us at 844-693-5747 and we would be happy to assist you.

REQUIRED: Upload your CV. *

Click or drag files to this area to upload. You can upload up to 5 files.

REQUIRED: Upload your National Practitioner Data Bank Report. *

Click or drag files to this area to upload. You can upload up to 5 files.

REQUIRED: Upload a 10-year Claim History report from your insurance carrier(s). *

Click or drag files to this area to upload. You can upload up to 5 files.

Upload Explanations and/or Claim Supplement Forms for YES responses in the ADDITIONAL UNDERWRITING INFORMATION section.

Click or drag files to this area to upload. You can upload up to 10 files.

If applicable, upload NICA Participant Certificate for current calendar year.

Click or drag files to this area to upload. You can upload up to 10 files.

PROVIDER REPRESENTATIONS

I hereby declare that the statements and responses I have provided in this questionnaire are, to the best of my knowledge and recollection, complete and correct and that I have not deliberately suppressed or misstated any material facts. If any material change occurs during the term of my policy, I agree to immediately notify the AAHP-RRG in writing at the following email address: InsuranceServices@SIPSAAHP.org

Signature *

Clear Signature

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