Acupuncture Application

Professional Liability Insurance Application for Claims-made Coverage

Medical Insurance Exchange of California
NATIONAL ACUPUNCTURE PURCHASING GROUP

When you submit this form, your responses will be displayed in a printable format along with subscriber's notices and agreement. Print the page, read it carefully, sign as necessary, enclose additional materials as directed and mail to address provided.

1.	Your full name Male Female
2.	Home address
	City, State, Zip
3.	Home phone Alternate phone
4.	Date of birth (mm/dd/yy) Place of birth (city, state & country)
5.	Social Security Number (xxx-xx-xxxx)
6.	Requested effective date of insurance (mm/dd/yy)
7.	Applicant is a member of association You must be a member of one of National Acupuncture Purchasing Group’s sponsoring associations and attach a copy of your membership card when you send your application
8.	Limits of liability	$1,000,000 per claim / $3,000,000 annual aggregate $500,000 per claim / $1,500,000 annual aggregate
9.	Applicant is	Solo Practice Partnership Corporation Other Employed acupuncturist - Employer
10.	Do you practice under a DBA or fictitious name? Yes No If yes, DBA name are you the sole provider under this name? Yes No
11.	Offices	PRIMARY	SECONDARY
	Address
	City, State, Zip
	Phone
	Fax
	Email

12.	Do you wish to be covered for professional premises (“slip and fall”) liability? There is no additional premium charge for this coverage, but it will be provided only if you request it. Not available for home offices.	Yes No
13.	When did you begin your practice of acupuncture? (mm/yy)
14.	Describe previous practice (Name of employer /practice) Name From (mm/yy) To (mm/yy)
15.	Do you currently have professional liability insurance? Name of carrier Policy No. Expiration date Limits of Liability If yes, please attach a copy of your current certificate of insurance.	Yes No
16.	If policy is claims-made, have you or do you intend to purchase “tail” coverage? If your recent coverage was a claims-made policy, you MUST either purchase "tail" coverage from your former carrier or apply for "prior acts" coverage. If you purchased tail coverage from your former carrier, send a copy of the endorsement. If you wish to be covered for prior acts, send a copy of the current policy declarations.	Yes No

17.	School attended Location from to Other training Location from to (acupuncture/undergraduate/graduate) (mm/yy)

18.	CA Acup. License No. Effective Date Please attach a copy of L.Ac. license	Is it current? Yes No
19.	Are you licensed in any other state? If yes where	Yes No

20.

Professional designation

L.Ac.
Chiropractor
MD/DO

Diplomat of Acupuncture
Physical Therapist
Other

21.	Do you advertise your practice? If yes, please attach a copy including flyers, handouts, etc.	Yes No
22.	Do you limit your practice to acupuncture as defined in Business and Professions Code Sections 4927 and 4937? If no, describe:	Yes No
23.	Do you or your employee(s) use disposable needles? If NO, please confirm that you use nondisposable needles in compliance with the statutes regarding reuse and sterilization of acupuncture needles. Attach a copy of CNT (Clean Needle Technique) certificate.*	Yes No
24.	Have you or your employee(s) ever been involved in a malpractice claim/suit? If yes, please send a separate narrative of each incident on letterhead.	Yes No
25.	Have you or your employee(s) ever been convicted of a felony?	Yes No
26.	Have you or your employee(s) ever been convicted of or entered a “no contest” plea to a crime, other than a traffic violation?	Yes No
27.	Have you or your employee(s) ever been investigated by a state or federal regulatory body?	Yes No
28.	Has any government agency ever suspended, revoked, restricted, placed you or your employee(s) on probation, or taken any other action against your license or your employee’s license?	Yes No
29.	Have you or your employee(s) ever been diagnosed as having or been treated for alcoholism or narcotics addiction?	Yes No
30.	Are you or your employee(s) being treated for any medical condition, disease, or illness that affects your ability to provide care or treatment?	Yes No
31.	Has any professional liability insurance carrier ever declined, cancelled, refused to renew, restricted, or surcharged you or your employee(s)?	Yes No
32.	Do you or your employee(s) perform any procedures involving direct moxabustion?*	Yes No
33.	Do you or your employee(s) perform acupuncture as anesthesia for the purpose of performing surgical procedures?*	Yes No
34.	Do you or your employee(s) perform acupuncture during labor and delivery?*	Yes No

35.

How did you hear about MIEC?

MIEC Loss Prevention seminar
Acupuncture association
Alumni mailing from acupuncture college and MIEC

Colleague referral
MIEC website
Annual meeting
Other

* These procedures are excluded under the MIEC policy. Any exceptions to these excluded procedures must be submitted to MIEC for approval.
IF YOU ANSWERED YES TO QUESTIONS 23-33, PLEASE PROVIDE DETAILS ON YOUR LETTERHEAD
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6250 Claremont Avenue Oakland, CA 94618
800.227.4527 Fax 510.654.4634