General Information



CNM
CPM
LM
Other:











Other Locations Used:













Yes
No


an Individual
a Corporation
a Partnership
a Joint Venture

Other (please describe):







1. Insurance History


  Expiring Policy: Prior: Prior:
Company Name
Expiration Date
Annual Premium
Coverage Limits

Home Births
Hospital
Clinics

Yes
No

Yes
No

2. Desired Insurance Limit of Liability:

$100,000 per accident / $300,000 aggregate
$200,000 per accident / $600,000 aggregate
$250,000 per accident / $750,000 aggregate
$250,000 per accident / $1,000,000 aggregate
$1,000,000 per accident / $3,000,000 aggregate

3. Business Activities


$

  Income
Births
Gynecology
Coaching / Doulas
Childbirth Education
Other
Total

Yes
No

Yes
No

Yes
No

  Full-Time: Part-Time:
Operational Staff
Non-Operational employees (drivers, collectors, supervisors, etc.)

Title Name Years With The Business Years of Experience

Yes
No

Yes
No




Yes
No

Birthing Centers Homes Hospitals

Birthing Centers Homes Hospitals

Year Birthing Centers Homes Hospitals
2009
2010
2011
2012
2013
2014

Yes
No

Yes
No

Yes
No

Yes
No

4. Education



From: To:



REPRESENTATIONS AND WARRANTIES

The “Applicant” is the party to be named as the “Insured” in any insuring contract if issued. By signing this Application, the Applicant for insurance hereby represents and warrants that the information provided in the Application, together with all supplemental information and documents provided in conjunction with the Application, is true, correct, inclusive of all relevant and material information necessary for the Insurer to accurately and completely assess the Application, and is not misleading in any way. The Applicant further represents that the Applicant understands and agrees as follows: (i) the Insurer can and will rely upon the Application and supplemental information provided by the Applicant, and any other relevant information, to assess the Applicant’s request for insurance coverage and to quote and potentially bind, price, and provide coverage; (ii) the Application and all supplemental information and documents provided in conjunction with the Application are warranties that will become a part of any coverage contract that may be issued; (iii) the submission of an Application or the payment of any premium does not obligate the Insurer to quote, bind, or provide insurance coverage; and (iv) in the event the Applicant has or does provide any false, misleading, or incomplete information in conjunction with the Application, any coverage provided will be deemed void from initial issuance.

The Applicant hereby authorizes the Insurer and its agents to gather any additional information the Insurer deems necessary to process the Application for quoting, binding, pricing, and providing insurance coverage including, but not limited to, gathering information from federal, state, and industry regulatory authorities, insurers, creditors, customers, financial institutions, and credit rating agencies. The Insurer has no obligation to gather any information nor verify any information received from the Applicant or any other person or entity. The Applicant expressly authorizes the release of information regarding the Applicant’s losses, financial information, or any regulatory compliance issues to this Insurer in conjunction with consideration of the Application.

The Applicant further represents that the Applicant understands and agrees the Insurer may: (i) present a quote with a Sublimit of liability for certain exposures, (ii) quote certain coverages with certain activities, events, services, or waivers excluded from the quote, and (iii) offer several optional quotes for consideration by the Applicant for insurance coverage. In the event coverage is offered, such coverage will not become effective until the Insurer’s accounting office receives the required premium payment.

The Applicant agrees that the Insurer and any party from whom the Insurer may request information in conjunction with the Application may treat the Applicant’s facsimile signature on the Application as an original signature for all purposes.

The Applicant acknowledges that under any insuring contract issued, the following provisions will apply:

1. A single Accident, or the accumulation of more than one Accident during the Policy Period, may cause the per Accident Limit and/or the annual aggregate maximum Limit of Liability to be exhausted, at which time the Insured will have no further benefits under the Policy.

2. The Insured may request the Insurer to reinstate the original Limit of Liability for the remainder of the Policy period for an additional coverage charge, as may be calculated and offered by the Insurer. The Insurer is under no obligation to accept the Insured’s request.

3. The Applicant understands and agrees that the Insurer has no obligation to notify the Insured of the possibility that the maximum Limit of Liability may be exhausted by any Accident or combination of Accidents that may occur during the Policy Period. The Insured must determine if additional coverage should be purchased. The Insurer is expressly not obligated to make a determination about additional coverage, nor advise the Insured concerning additional coverage.

4. The Insurer is herein released and relieved from any and all responsibility to notify the Insured of the possible reduction in any applicable Limit of Liability. The Insured herein assumes the sole and individual responsibility to evaluate, consider, and initiate a request for additional coverage or reinstatement of the annual aggregate Limit of Liability which may be exhausted by any single Accident or combination of Accidents during the Policy Period.

Dated:
Applicant:

 

Dated:
Agent/Broker:

Southern Cross Insurance Solutions, LLC.

P.O. Box 568428

Orlando, FL 32856

Ph (888) 985-3542

Fx (407) 985-3556

ageisler@southerncrossins.com


ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON,
FILES AN APPLICATION FOR INSURANCE CONTAINING FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY MATERIAL FACT THERETO, COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.


Coverage provided under any Policy/Certificate is contingent on the following warranty, requirements,
and acknowledgements as evidenced by the Named Insured’s signature.

In lieu of the required insurance company loss runs to document the prior loss history of the Named Insured, the
following claims history summary, which includes a listing of all losses, claims, and incidences which have
occurred at any time during the last five years that may reasonably result in a claim or loss, is presented as a
supplement to the application and will serve as a warranty statement and become an express part of the
Policy/Certificate.

Policy Year Date of Loss/Claim/Incident Description of Loss/Claim/Incident Amount Paid

Acknowledgement and Warranty Statement

“As an authorized representative of the Named Insured, I warrant that: (i) the loss history provided on or
with this form represents all claims, losses, incidents, occurrences, events or circumstances, which the
Named Insured knows about or should reasonably know about; (ii) no accident or incident has taken
place which has not been revealed which could reasonably be expected to result in a claim, and further,
that the claims history provided herein is true, correct, and complete, and (iii) the Named Insured does not
possess any other information which would affect the Insurer’s ability to accurately understand, assess,
and rate the risk to be insured.”





This Claim Information Supplement must be completed, signed, and dated by the Applicant for each Claim, Suit,
or circumstance reported on your Application for insurance and the history above. All questions must be
answered completely. If any question does not apply, indicate “NOT APPLICABLE.”

Information:

Name Social Security Number or EIN

Claim or Circumstance Information:

Claimant Name Age Sex
Date of Alleged Incident Date Claim was made or Suit brought
Additional Defendants
Insurance Carrier to Whom Claim/Circumstance Reported:

Claim Status:

Dismissed: Defense Verdict:
Plaintiff Verdict: Total Paid: Paid on Your Behalf:
Settlement: Total Paid: Paid on Your Behalf:
Open:
Settlement Demand: Settlement Offer: Loss Reserve:

For all Paid and Reserve amounts, include both Indemnity and Expense dollars.

Claim Description: Include allegation(s), events leading up to the Claim, and any other facts pertinent to the Claim

The Applicant declares that the information contained in this Claim Information Supplement is true and that no material facts have been suppressed or misstated.



Please include any additional comments.