NJ PURE | Renewal Application Questionnaire

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RENEWAL APPLICATION QUESTIONNAIRE

As part of the renewal process, please complete the following Renewal Application Questionnaire and return it along with any additional documentation via email to RQ@njpure.com or fax (609) 520-0225.

POLICYHOLDER INFORMATION

FIRST NAME*

LAST NAME*

SUFFIX*

STREET*

CITY*

STATE*

ZIP*

EMAIL ADDRESS*

POLICY NUMBER*

CLAIMS INFORMATION UPDATE

For any “Yes” answer below, please provide a detailed narrative. For claims, please include the plaintiff’s initials, incident date, report date, status, settlement amount, settlement date and insurance company. This is to include medical records requests for litigation.

Do you know of any new circumstance, act, error or omission that could possibly result in a professional liability claim against you in the past 12 months?*
Yes No
Do you have any new claims or status changes to previously open claims, including those that have been closed with or without indemnity payment in the past 12 months?*
Yes No

Please note: You may be asked to provide an updated claims history statement from each of your previous insurers within the last ten years.

PRACTICE INFORMATION UPDATE

For any “Yes” answer below, please provide additional details and full documentation from any agency involved.

Have there been any changes to your practice, including locations, hours, procedures, treatments, employed medical professionals and/or corporate structure, in the past 12 months?*
Yes No
Has there been a status change to any of your professional licenses held or hospital privileges in the past 12 months?*
Yes No
Have you been under investigation by any medical board, state or federal regulatory authority, including being arrested or indicted for any criminal offense in the past 12 months?*
Yes No

INSURED SIGNATURE

I hereby declare that the statements on this questionnaire are true. I acknowledge that the submission of complete and accurate information to NJ PURE is necessary for proper underwriting and rating of my renewal application.

I agree and state that I am in compliance with all applicable state and federal laws, rules, and regulations governing my medical license.

I understand and agree that any false or misleading information or material misrepresentation or omission by me in this renewal application questionnaire will void coverage from the inception date of the contract. Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Full Name

Date

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