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Section I A. CHART Hospital B. Physician Name MD DO DPM C. Date of Birth D. Place of Birth E. Specialty Practiced for this Employer F. Sub Specialty G. Medical License No. H. Email Address I. Office Phone No. Section II A. Requested Effective Date of CHART Coverage:B. CHART Coverage Requested: Per Occurrence * If Claims Made, retro date will be the same as effective date unless Prior Acts are being requested *If requesting PRIOR ACTS coverage, you are required to complete the PRIOR ACTS SUPPLEMENT. PRIOR ACTS coverage is NOT available for work/services provided outside of Pennsylvania, West Virginia, and New York.

C. Current Insurer: D. Current Coverage: Per Occurrence Claims Made If Claims Made, provide Retro Date*

*I understand the unique nature of claims made coverage and the importance of securing a reporting endorsement via the purchase of TAIL coverage from your current insurer or via PRIOR ACTS coverage through CHART

(please initial)

E. Limits Requested: PA Hospitals: $500,000/$1,500,000 INDIVIDUAL LIMITS (Mcare participation required) (Check one) NY Hospitals: $1,000,000/$3,000,000 SHARED LIMITS OR $2,300,000/$6,900,000 INDIVIDUAL LIMITS WV Hospitals: $1,000,000/$3,000,000 SHARED OR INDIVIDUAL LIMITS (determined by the hospital) F. Do you require coverage for professional services outside of your SCOPE of duties with this hospital? YES NO G. Will you carry any other insurance for these professional services? YES NO H. Has your professional liability insurance ever been declined, non-renewed, cancelled, or restricted? YES NO

If yes to any of the 3 questions listed above, full descriptions must accompany this application.

Section III A. How many clinical hours per week will you be working? Information contained below must include all sites where you are requesting CHART to insure your activities. Percentage should be based on number of patients treated.

B. Office Practice Location(s) (must total 100%): 1.

Name of Practice Address City State Zip Code Percent Part of Scope

2. Name of Practice Address City State Zip Code Percent Part of Scope

NEW APPLICATION Physician

Professional Liability Insurance ALL SECTIONS OF THIS FORM ARE REQUIRED. THE INFORMATION CONTAINEDWITHIN WILL BE USED FOR UNDERWRITING AND RATING PURPOSES. IT DOES NOT CONFIRM THAT COVERAGE IS GRANTED.

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C. Hospital Location(s) (must total 100%): 1.

Name of Hospital City State Zip Code Percent Part of Scope

2.

Name of Hospital City State Zip Code Percent Part of Scope

D. Other locations-Includes any free standing ambulatory care facilities, nursing homes, urgi-centers, surgi-centers, schools, employment physicals, etc.: 1.

Facility Address City State Zip Code Type of Privileges Hrs/Week Part of Scope

2.

Facility Address City State Zip Code Type of Privileges Hrs/Week Part of Scope

Section IV A. Medical School City State Year Graduated Degree B. Internship City State From (Month and Year) To (Month and Year) Type of Internship C. Residency City State From (Month and Year) To (Month and Year) Type of Residency D. Additional Training/Fellowship City State From (Month and Year) To (Month and Year) Type of Training E. Will you be a part of a Residency/Fellowship Program after the requested date of coverage? YES NO If yes, completion date

F. Are you currently American Board Certified? YES NO If yes, provide board name Specialty Date Originally Certified

If not American Board certified, are you certified by another board or certifying body? YES NO Name of certifying body G. Are you participating in a Maintenance of Certification Program? YES NO

Section V

Must attach a current Curriculum Vitae accounting for all years since completion of formal training (include complete addresses). Must

include any military or public service organizations. A NARRATIVE REGARDING GAPS IN WORK/TRAINING MUST BE INCLUDED.

Section VI

A. GENERAL SURGEONS PLEASE PROVIDE THE FOLLOWING PERCENTAGES: OB/GYN Surgery % Neurosurgery % Orthopedic Surgery %

Plastic Surgery % Bariatric Surgery %

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B. ALL OTHERS, PLEASE PROVIDE THE FOLLOWING PERCENTAGES: No Surgery % Minor Surgery % Major Surgery % C. Must attach a copy of your Delineation of Privileges

for this

CHART insured hospital

D. Will you perform any procedures outside of your Scope of Duties with this CHART insured hospital? YES NO E. Will you practice in the ER of this CHART insured hospital? YES NO If yes, how many hours per week? F. Will you treat prisoners outside of those who present to this CHART insured hospital? YES NO G. Will you provide services via the Internet or telemedicine? YES NO

Section VII

A. What is your relationship to this CHART insured hospital: Hospital Employee Independent Contractor Employee of Individual/Group (not a shareholder/partner) OtherB. Name of Hospital Employer, Corporation, LLC, Partnership, etc. for which you are a member C. Is coverage required for the Corporation, LLC, Partnership, etc.? YES NO

Section VIII (refer to Warranty section of this application for additional information) APPLICANTS MUST PROVIDE A “SELF-QUERY” COPY OF THE NATIONAL PRACTITIONER DATA BANK REPORT WITH THIS APPLICATION A. Are you aware of any incidents that could result in a claim, requests for medical records, etc.? YES NO

Have these incidents been reported to your current insurance carrier(s)? YES NO B. Are there any other claims or incidents which may result in a claim that are NOT INCLUDED in the attached Data Bank Report and/or are NOT INCLUDED on the OPEN CLAIMS SUPPLEMENT attached? YES NO C. Have there been any other payments made relative to medical care provided by you which were resolved with a monetary payment by you or on behalf of you? YES NO

If yes to A, B, and/or C above, attach a narrative including all available details. Please complete the OPEN CLAIMS SUPPLEMENT at the end of this application (closed claims will be reported through the National Practitioner Data Bank (NPDB) report)

Section IX

A. Have any of the following been denied, suspended, restricted, revoked, or voluntarily surrendered: State Med License YES NO Hospital Privileges YES NO

License to Prescribe Meds YES NO B. Have you: Undergone psychiatric treatment? YES NO

Been treated for alcohol/narcotics addiction? YES NO Any chronic illness/physical defect that would impair your duties? YES NO Been convicted of a misdemeanor/felony other than traffic violation? YES NO Appeared before a Professional Standards/Quality Assurance Review Committee? YES NO Appeared before the Board of Medical Examiners or Medical Licensure Board? YES NO Provide details:

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OPEN CLAIMS SUPPLEMENT

List All Open Claims

1. Physician Name 2. Name of Claimant 3. Claimant Age at Time of Incident 4. Treatment Date 5. Incident Occur During Residency or Fellowship? (if yes, choose one) 6. Insurer Defending Physician 7. Suit Filed? YES NO If yes, date filed

8. Are you Primary Defendant? YES NO 9. Current Status 10. Claim Reserve Established? YES NO If yes, specify amount 11. Provide a narrative of the medical incident/facts:

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MEDICAL DIRECTOR SUPPLEMENT

Must be completed if employed or contracted by any facility other than the CHART hospital identified in Section I. A. of this application as a Medical

Director or in a similar role

Physician Name: 1. Name of the facility: 2. Type of facility: Inpatient: Outpatient 3. Are you: employed contracted by the facility 4. Who is responsible for providing the Medical Professional Liability Insurance for this position? If you are, you must provide a copy of the contract stating such

5. Details regarding your duties 6. Do you supervise staff? YES NO If yes, how many people? 7. Does this facility provide Directors and Officers Liability Insurance for your role as Medical Director? YES NO NOTE: CHART DOES NOT PROVIDE COVERAGE FOR LIABILITY ARISING OUT OF ERRORS AND OMISSIONS IN THE CAPACITY OF MEDICAL DIRECTOR Signature Date

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PRIOR ACTS SUPPLEMENT

Do not forfeit your right to purchase the Extended Reporting Coverage (Tail Coverage) from your current insurer until you receive formal acceptance of

Prior Acts coverage through CHART

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I acknowledge that I am requesting coverage for Prior Acts and understand that CHART does not provide this coverage for services outside of Pennsylvania, West Virginia, and New York. I also acknowledge that this coverage is subject to CHART underwriting guidelines and approval and is NOT AUTOMATIC.

REQUIRED ATTACHMENTS: 1. Complete copy of your current Professional Liability policy, including endorsements 2. A brief narrative regarding the MEDICAL SPECIALTY and MEDICAL SERVICES for which I am requesting Prior Acts coverage: a. Type of Privileges during the Prior Acts period b. Name and Location (City and State) of all hospitals involved in the Prior Acts period c. Complete list of services provided during the Prior Acts time period (even though you may not currently provide those services) Signature Date

Physician Name Medical License No.

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OMNIBUS WARRANTY

PLEASE READ CAREFULLY

1. I hereby declare that, to the best of my knowledge, information and belief: a. all of my statements and responses in the foregoing application are true and correct; b. all CLOSED claims previously filed against me relative to medical care I provided, which were resolved with a monetary payment by me or on my behalf, have

been identified and described either in responses submitted in this application or in the attached NATIONAL PRACTITIONER DATA BANK SELF-QUERY REPORT, and the information submitted regarding these claims is true and correct to the best of my knowledge and belief;

c. the statements and information contained in the OPEN CLAIMS SUPPLEMENT are a true and correct representation of all OPEN claims against me related to medical care I provided;

d. I have not knowingly withheld any information which could be expected to influence my Professional Liability insurance provided through CHART; e. I have provided complete details available to me at this time regarding any potential claim or incident as requested in this application. f. I understand that any material misrepresentation or inaccuracy in this document and attachments shall void coverage.

2. If I am seeking coverage for PRIOR ACTS, I hereby declare that I have reported all previously known lawsuits, incidents, and circumstances that could reasonably be

expected to result in a claim to my current insurer and will continue to report such lawsuits, incidents and circumstances to my current insurer until such time as my coverage through CHART is effective. I understand and acknowledge that CHART will not cover any lawsuits or claims based upon incidents or circumstances of which I had knowledge and which could reasonably be expected to result in a claim prior to my inception of CHART coverage, whether or not such incidents, facts, or claims were reported to my prior insurer.

3. I hereby authorize CHART to obtain full information from any person or insurance company with respect to any claim or suit pertaining to professional acts or

omissions asserted against me. I further authorize and consent to the release of information by a hospital and/or facility, its medical staff, medical associations or licensure board on request regarding any information they may have concerning my staff privileges and/or licensure.

4. I understand if my practice/duties change from the description outlined in this application, I must notify CHART immediately. If claims are submitted to CHART

based upon my performance of duties beyond those described herein prior to notification to CHART of such change, any such claim may be subject to a denial of coverage under this policy.

5. Scope of Professional Practice for Mid-Wives and Family or General Practice Physicians Providing Obstetrical Medical Services: The undersigned hereby

represents and warrants that an Obstetrician will supervise, manage, preside over and be present at all times during the labor and delivery for a Vaginal Birth after Cesarean Section (VBAC) that is attended by me. The undersigned understands that this Policy’s coverage is being provided in reliance upon this warranty, among others, and that any breach thereof may result in a denial or rescission of coverage.

6. I understand that this application is subject to acceptance by CHART and does not bind coverage. 7. NOTICE - State of PA: Any person who knowingly and with the intent to defraud any insurance company or other person, files an application for insurance or

statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties.

8. NOTICE - State of NY: Any person who knowingly and with the intent to defraud any insurance company or other person, files an application for insurance or

statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime and subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each violation.

Signature Date

ATTACHMENTS REQUIRED Verified that documents are attached

1. Current Curriculum Vitae YES NO

2. Current Data Bank Report YES NO

3. Prior Acts Form (if needed) YES NO and corresponding attachments

4. Medical Director Form, (if needed) YES NO including a copy of your contract

5. Dilineation of Privileges YES NO