Application Form 2019-07-03T22:53:08+00:00

PROFESSIONAL LIABILITY INSURANCE APPLICATION

In order to submit the form you are required to answer every question below. If the questions are not applicable to your practice enter NA.

COVERAGES LIMITS OF LIABILITY DATE COVERAGE to be EFFECTIVE
Professional Liability
Claims Made Policy
Each Claim
$l,000,000
Annual Aggregate
$3,000,000

  • (If foreign dental school graduate are you certified by the Educational Council for Dental School Graduates?

    Yes 
    Yes 
  • Type of practice or certified specialty
    General Practitioner 
    Endodontist 
    Oral Pathologist 
    Pediatric Dentist 
    Periodontist 
    Orthodontist 
    Prosthodontist 
    Other 
  • Name all places where you have practiced your profession since graduation
  • You will need to furnish a Claims/Loss Run from each prior carrier. This document must state the carrier name, specific years of prior coverage and any claims history you may have.
  • What professional organizations are you a member of?
    ADA 
    UDA 
    AGD 
    Other 
  • Do or will you practice as :

    Solo Practioner? 
    Partner or Associate in Group Practice? 
  • Are you employed full time by the Federal Government or currently engaged in military service?

    Yes 
    No 
  • Do you own or plan to own/operate a training facility for dental assistants or auxiliaries?

    Yes 
    No 
  • Has any hospital ever restricted or revoked privileges or put you under probation?

    Yes 
    No 
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    PROFESSIONAL LIABILITY INSURANCE APPLICATION, Page 2

  • Have you ever been denied a dental license or been denied certification by a specialty board?

    Yes 
    No 
  • Have you had any hearings or investigations before the Department of Occupational and Professional Licensing in Utah or before the Dental Board of any other State?

    Yes 
    No 
  • Has your dental license ever been suspended, revoked, or voluntarily surrendered, or has probation on your license ever been imposed in any state where you have been licensed?

    Yes 
    No 
  • Has your state license to prescribe or DEA Number ever been suspended, revoked, or voluntarily surrendered?

    Yes 
    No 
  • Have you ever been convicted or pled guilty to a felony crime?

    Yes 
    No 
  • Has any dental malpractice claim ever been made against you?

    Yes 
    No 
  • Has any malpractice insurance carrier ever cancelled or refused coverage?

    Yes 
    No 
  • Are you now or have you ever voluntarily or involuntarily participated in a diversion program or rehabilitation program for drug or alcohol abuse?

    Yes 
    No 
  • Have you been investigated by a state association or component society peer review committee?

    Yes 
    No 
  • Have there been any serious or life-threatening incidents in your practice?

    Yes 
    No 
  • Do you plan on having your dental hygienist(s) give local anesthetics?

    Yes 
    No 

    If yes, does he/she have her own coverage?

    Yes 
    No 
    If not, you will need to purchase the PIE “H Rider.” All dentists in a group or partnership, etc, including associates, must obtain this H-Rider to avoid coverage gaps.
  • Check if you do any of the following procedures:
    A  
    Nitrous Oxide Analgesia 
      (Requires PIE Class I Cov. + Class II Anesthesia Permit with Dental License)
    B  
    In-office IV sedation provided by other professional 
      (Requires. PIE Class II Coverage)
    C  
    IV or General Anesthesia provided by other professional in hospital/other setting 
      (Req. PIE Class II Coverage)
    THOSE ANSWERING #25 D OR E BELOW MUST FILL OUT QUESTIONS ON PAGE 3
    D  
    In-office IV/IM sedation provided by you personally 
      (Req. PIE Cl. II + Class III Anesthesia Permit)
    E  
    Oral/enteral conscious sedation 
      (Requires PIE Class II Coverage + Class II Anesthesia Permit)
  • Are you currently CPR Certified?

    Yes 
    No 

    Up to date on required CE Hours?

    Yes 
    No 
  • Have you established emergency procedures, personnel and equipment to cope with patient emergencies, such as cardiac arrest, anaphylactic shock, etc.?

    Yes 
    No 
  • Answer each of the following with regard to your current office procedures:
    If you are starting a new practice, answer each question as you intend to practice
    1. Do you keep a record of pertinent patient phone calls regarding treatment?

      Yes 
      No 
    2. Do you document and verify all patient referrals to specialists?

      Yes 
      No 
    3. Do you plan to have patients sign a Consent to Proceed plus detailed Consent forms for specific procedures? PIE will furnish example forms.

      Yes 
      No 
  • Are you affiliated with any Dental School Faculty?

    Yes 
    No 
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT ANY FALSE STATEMENTS OR UNLAWFUL ACTS WILL RENDER MY COVERAGE NULL AND VOID.

Signing this application does not bind the Company to provide insurance but it is agreed that this form shall be the basis of the contract should this policy be issued. If accepted for insurance, I authorize PIE to release personally identifiable financial information as applicable to affiliates and non-affiliates disclosed on the PIE Privacy Policy statement for purposes of reinsurance premium calculation, etc.

Signature

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PIE APPLICATION, Page 3

    If you use Valium or Vistaril or nitrous oxide only for sedation you do not need to fill out this form

    SUPPLEMENTAL QUESTIONS FOR DENTISTS WHO PROVIDE CONSCIOUS ORAL/ENTERAL SEDATION

    YOU MUST CARRY PIE CLASS II COVERAGE IF YOU PROVIDE ENTERAL OR PARENTERAL SEDATION

  • Are you using the following recommended monitoring device, etc?

    Pulse oximeter

    Yes 
    No 

    Current emergency drugs

    Yes 
    No 

    Positive pressure oxygen

    Yes 
    No 
  • Do all patients who undergo oral conscious sedation sign a written informed consent form specific for oral sedation that has been reviewed and approved by PIE?

    Yes 
    No 
  • Do you have patients complete a health history form within one week of a scheduled procedure that expresses no contraindications to the use of oral sedative agents?

    Yes 
    No 
  • Do you keep a supply of reversal drugs (e.g. Romazicon) available?

    Yes 
    No 
  • Do you log vital signs at specific intervals during the procedure?

    Yes 
    No 
  • Do you limit the oral sedation technique to patients over 18 and under 60 years old, or have you taken an advanced course on sedation for children and elderly pts?

    Yes 
    No 
  • Furnish copy of Course Attendance Certificate.

    PIE requires you to take a refresher course every three years

    SUPPLEMENTAL QUESTIONS FOR DENTISTS WHO PERFORM THEIR OWN IV/IM/PARENTERAL SEDATION
  • Are you in compliance with all equipment and monitoring requirements as specified in R156-69-601 of the Utah Practice Act, including

    Pulse oximetry

    Yes 
    No 

    Current emergency drugs

    Yes 
    No 

    Positive pressure oxygen

    Yes 
    No 
  • Do all patients who undergo parenteral sedation sign an informed consent form specific for parenteral sedation that has been reviewed and approved by PIE?

    Yes 
    No 
  • Do you utilize a third person (besides you and your dental assistant) whose sole duty is to monitor the patient and record pertinent data during the procedure?

    Yes 
    No 
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT ANY FALSE STATEMENTS OR UNLAWFUL ACTS WILL RENDER MY COVERAGE NULL AND VOID

Signature

Page 3

    SUPPLEMENTAL QUESTIONS FOR RECENT GRADUATES

    Please answer the following questions if you were graduated from dental school within five years of submitting this application:

  • Did you ever fail any portion of your National Board Examinations?

    Yes 
    No 
  • Did you fail any course, clinical or didactic, during dental school?

    Yes 
    No 
    If yes, state course and date of remedial coursework, including grade:
  • Did you have to repeat any of the above courses more than once?

    Yes 
    No 
  • Did you graduate on time, i.e. on the date that your dental school class was scheduled to graduate?

    Yes 
    No 
  • Did you pass the above state or regional examinations on your first attempt?

    Yes 
    No 
  • Did you ever fail a state or Regional Licensing Board Examination?

    Yes 
    no 
    If yes, list Examination(s) failed, date(s), and section(s) failed:
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT ANY FALSE STATEMENTS OR UNLAWFUL ACTS WILL RENDER MY COVERAGE NULL AND VOID.

Signature

Page 4

SUBSCRIBER’S AGREEMENT

WHEREAS, the undersigned is a resident of the State of Utah and is licensed to practice dentistry in the State of Utah;

WHEREAS, the undersigned desires to enter into membership among other subscribers of a mutual insurance company providing indemnity against professional liability, said mutual insurance Company shall be known as Professional Insurance Exchange Mutual, Inc. (PIE)

NOW THEREFORE, the undersigned agrees with PIE and the other subscribers

  • To join with the other subscribers insuring against losses and to be subject to such terms and conditions and limits of liability as set forth in the policy. The terms, conditions and limits of liability of the policy shall be specified by the Company in compliance with sound and accepted insurance practices and reasonable standards established by the Subscribers' liability set forth herein.
  • To make all premium payments and applicable surcharge payments when due for policies of insurance issued in accordance with schedules of rates prepared from time to time by the Company in compliance with sound and accepted insurance practices and reasonable standards established by the Company’s Board of Directors and approved by the Commissioner of Insurance of the state of Utah
  • To abide by such rules and regulations of the Company as stated in the Bylaws or adopted by the Company’s Board of Directors from time to time.
  • To release all past and current information pertaining to underwriting and claims by the undersigned's prior insurers or their agents.
  • To the appointment of Richard C. Engar, D.D.S. as Chief Executive Officer (CEO) to administer the day-to-day operations of the Company and oversee underwriting of potential new subscribers.
  • To allow the Subscribers' Board of Directors to supervise and control the activities of the Company.
  • To authorize PIE to release personally identifiable financial information as applicable to affiliates and non-affiliates disclosed on the PIE Privacy Policies statement for purposes of reinsurance premium calculation, etc.

IT IS FURTHER AGREED that the subscribers' Board of Directors shall consist of nine members elected at the annual meeting of subscribers by the subscribers exercising one vote each. Board members shall be elected for terms of three years each. Terms shall be staggered such that three positions are due for election each year. Not less than eight such Board members shall be subscribers or members of PIE. The Subscribers' Board of Directors shall supervise the finances of Professional Insurance Exchange Mutual, Inc. and supervise its operations to assure conformity with this Agreement and the Bylaws of the Company, procure examinations or audits of the accounts and records of Professional Insurance Exchange Mutual, Inc. and shall have such additional powers and functions as may be conferred from time to time by majority vote of the subscribers.

, Utah,

Signature

Please type or print your name and residence address:

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