Indiana Patient's Compensation Fund - Filings

May 29, 2007 Bulletin 148 Indiana Patient's Compensation Fund - Filings This Bulletin is directed to all insurers that provide coverage to health care providers under Indiana's Medical Malpractice Act. Portions ofBulletin 119 relating to the Certificate of Insurance are hereby withdrawn and replaced by this Bulletin 148. All other provisions of Bulletin 119 remain in effect. Pursuant to IC 34-18-3-2 a health care provider may qualify under the Indiana Medical Malpractice Act by filing with the Department of Insurance proofof financial responsibility and payment ofa surcharge to the Indiana Patient's Compensation Fund. Attached to this Bulletin as Exhibit A is the certificate that shall be used when filing proof of financial responsibility with the Patient's Compensation Fund on or after July 1, 2007. INDIANA DEPARTMENT OF INSURANCE ~ ---- EXHIBIT A CERTIFICATE OF INSURANCE TO: IND1ANA PATIEt,ff'S COMPENSATION FUND MEDICAL MALPRACTICE DMSION 311 W. WASHINGTON ST. STE.300 INDIANAPOLIS, IN 46204-2787 Surcharge Effective Date Cancellation: □ $ Return Surcharge □ $-~-- Additional Surcharge □ $~~ Surcharge Change Reason;-~------------ Health Care Provider: Medical License No. (Individual): EIN# (Entity): Please do not provide individual social security number Address (Street, City, State, Zip): County of Service: Policy No.; Occurrence □ RelroDate {CM or RP) Including employees D Claims Made □ Reporting Endors. □ Excluding employees D Coverage Dates: From: To: Date Surcharge Rec'd from Provider: Limits of Liability: $ per occurrence $ annual a.;,;.rregate Premium: (JNP/LOnly) Surcharge: Under90 day Penalty: Over90 Day Penalty: The following credits are only available for health care providers identified under Rule 60: Credits: (Only one credit maybe applied) Part-Time Credits Medical School Faculty 067% Newly Licensed Physicians Fellowship 0 0-12 hrs. 75% D Full-Time 50% □ 13-25 hrs. 50% 0 l st yr. 50% Greater of: D Full-time surcharge for rnedical practice out$lde □ 26-30 hrs 25% 02nd yr. 25% >-=· fellowship 0 Retired D 50% of surcharge due for specialty class offellowship Insurance Carrier Name; NAIC# Contact Name: Te!t~phone Number/Email: The undersigned Insurance Company/Broker, hereby certifies limits of liability on behalf ofthe above referenced Hedith Care Provider of not less than Two Hundred and Fifty Thou.sand ($250,000) Dollars for eaeh occurrence and with an annual aggregate of Seven Hundred and Fifty Thousand ($750,000) Dollars as required, unless otherwise mandated by statute, for claims against said Health Care Provider as a result ofMedical Malpractice, or allegation thereof; within the State of Indiana, and forther that said policy ofinsurance complies in all respects with the provisions of the Indiana Patient's Compensation Act Indiana Code 34-18-1-l et seq. It is further certified that the surcharge for the above referenced coverage for the period specified in this policy is at the appropriate Class rate for the named specialty, is based upon the published calculation for a hospital or nursing home, or is One Hundred and Ten Percent { 110%) of the premium for non-physician, non-hospital or non-nursing home providers. Said Company/Broker also agrees to collect and remit the rated surcharge or a minimum surcharge of one hundred ($100.00) dollars, whichever is larger, for each year of the period ofcoverage to the Department of Insurance, Patient's Compensation Fund, State oflndiana., within thirty (30) days of receipt but not more than sixty (60) days from the effective date of said policy. It is further acknowledged that in the event oftermination ofthe policy herein certified, or any reduction ofliability limit, such termination or change shall not be effective unless notice ofsame has been delivered to !he Department oflnsurance, State ofIndiana, not less than thirty (30) days prior to such change. Notice shall be considered to have been given upon placing same in the United States Mail by First Class Certified Mail, a copy of which shall have been mailed to !he health care provider. Dated this __ day of 20 at the insurance office of Signed by: Authorized Signature Primed: Title: ISO Code: