HomeMy WebLinkAbout07070172 Certificate of Insurance
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CERTIFICATE OF' INSURANCE
To INDIANA PATIENT'S COMPENSATION FUND
MEDICAL MALPRACTICE DIVISION
31 I W. W ASHJNGTON ST. STE. 300
INDIANAPOLIS, IN 46204-2787
Cancellation:
Retum/Additional Surcharge
Credit
Surcharge
o $
o $
o %
Effective Date
Occurrence l.'9
Policy No.: Claims Made 0 Rerro Date
MP00904367
Reporting Endvrs. 0 Retro Date
Health Care Provider:
Michael Wasserstrom DC
Medical Ljcensc No.. Including Employees 0 Excluding Employees 0
08001875
Address (Street, City, Stare. Zip):
120 E Carmel Dr County:
Carmel, IN 46032 HAMILTON
Coverage Dates: Classification Number:
From: 10/28/2006 To: 10/28/2007 80410
Limits of Liability: Premium Amount: $888.00
$250,000 per $750,000 annual Surcharge Amount: $976.80
occurence aggregate
Penalty Amount
The undersigned Insurance Company, hereby certifies limits of liability on behalf of the above referenced Health Care
Provider of not less thao Two Hundred and Fifty Thousand ($250,000) Dollars for each occurrence and with an annual
aggregate of Seven Hundred and Fifty Thousand ($750,000) Dollars as required, unless otherwise mandaled by statute,
for claims against said Health Care Provider as a result of Medical Malpractice, or allegation thereof. within the State of
Indiana, and further that said policy of insurance complies in all respects with the provisions of the Indiana Patient's
Compensation Act Indiana Code 34-18-1-1 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 is One Hundred
and Ten Percent (110%) of the premium for non-physician Or non-hospital providers. Said Company 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 of coverage to the Department of Insurance, Patient's Compensation Fund, State of Indiana, within
thirty (30) days and not more than ninety (90) days from the effective date of said poliey.
It is further acknowledged that in the event of termination of the policy herein certified, or any reduction of liability limit,
such termination or change shall not be effective unless notice of same has been delivered Lo the Department of Insurance,
State of Jndiaoa, 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 the health
care provider.
Dated thiS 16th day of October, 2006t the insurance office of NCMIC INSURANCE COMPANY
Signed by: --&~~
Autnonzea ~lgnature
Printed: Roger Schlueter
Title: COlporate Secretary
Pac-3/Stflte FOl1l12713R5
Revised 04/17/05
6. Legal fees and damages incurred in the defense or investigation of a claim or suit that arises out of
your chiropractic utilization review services, including the rendering of an opinion on the adequacy,
necessity or reasonableness of care furnished by another chiropractor based on the review of the
patient's records without a physical examination. Supplementary payments lor legal fees and
damages under this section will be limited to $25,000 per occurrence and $50,000 aggregate for all
actions arising during the policy period.
7. Legal fees and damages incurred in the defense or investigation of a claim or suit that arises out of
your peer review services, including services as a member of a formal accreditation, standards
review or other professional board or committee related only to chiropractic. Peer review means the
evaluation of the professional services rendered by another chiropractor for the purpose of
determining the qualifications and/or the competency of the chiropractor. Supplementary payments
for legal fees and damages under this section will be limited to $25,000 per occurrence and $50,000
aggregate for all actions arising during the policy period.
8. Legal fees and expenses to defend you in a revocation, suspension or disciplinary action bet ore tbe
State Licensing Board commencing during the policy period. Supplementary payments under this
section shall be limited to $5;000 per action and $10,000 per policy period. Further, no payments
will be made for any appeal after the State Licensing Board has rendered a final decision.
Your consent is not needed to make any payment under the "Supplementary Payments" section of this policy.
Further, this section does not change any other terms or conditions of this policy.
Persons Insured
The persons insured under this policy are:
I. The insured listed on the Declarations.
2. Any professional entity utilized for delivelY of professional services as listed on the Declarations.
3. Each chiropractic assistant, nurse or unlicensed ancillary personnel employed by you, but only if
they are acting within the scope and course of their duties as such in the providing of professional
services. Also, they must be under the supervision, if required by state law, of a licensed
chiropractor.
4. Locum Tenens temporarily employed by and serving in the place of an insured. Coverage for
locum tenens for anyone insured shall not exceed 60 days per policy period. An insured must
submit an application for the locum tenens and obtain our underwriting approval before coverage
for any locum tenens will be provided.
"Persons Insured" does not include any other licensed health care providers, including but not limited to other
licensed chiropractors, except the insured.
Territory
This policy applies to the providing of or failure to provide professional services anywhere in the world,
provided the claim or suit is brought within the United States of America, its territories or possessions, or
Canada.
Form MP2006
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