AAO INSURANCE COMPANY,A Risk Retention Group
This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your State. State insurance insolvency guaranty funds are not available for your risk retention group.
Home office: Scottsdale, AZ If you have any questions, please call 800-240-2650.
APPLICANT INSTRUCTIONS
- All questions must be answered completely. Please type or print clearly in ink.
- The application and all supplemental forms must be signed in ink and dated by the applicant.
Part I. GENERAL POLICY INFORMATION
Please indicate any changes in the policy information
Policy Number: / Current Policy Limits: / Policy Type:
Name:
1. Primary Office Location
Street / Total practice hours per week in this office: / Required!
City / County / State / Zip
Name of Corporation, Partnership insured under this policy:
Primary Office Phone Number / Primary Fax Number / Primary Office Business Manager Contact:
2. Secondary Office Location
Street / Total practice hours per week in this office: / Required!
City / County / State / Zip
Secondary Office Phone Number / Secondary Fax Number / Secondary Office Business Manager Contact
3. Additional Office Locations (if more than 3 office locations, please attach separate page)
Street CityStateZip Code / Total practice hours per week in this office: / Required!
4. Mailing Address: 1. Primary Location 2. Secondary Location
Other: / E-Mail Address:
5. Additional Dental License Information:
State: License #: Date Licensed: Expiration Date:
State: License #: Date Licensed: Expiration Date:
6. a. Do you teach or supervise students in any graduate orthodontic program? Yes No
If Yes, please indicate which program: ______
If Yes, are you full-time faculty ______or part-time faculty ______?
b. Does this program provide you with professional liability insurance for your clinical supervision of students? Yes No
c. IfNo, are you requesting coverage for clinical supervision of students? Yes No
If you are requesting insurance, list the address above or on a separate page.
PART II. POLICY CHANGES *COMPLETE ONLY IF CHANGING COVERAGE*
7. Are you seeking part-time coverage (consistently practicing less than 20 hours total per week in all locations)? Yes No
8. Change coverage to: (occurrence/aggregate)
a. $1,000,000/$3,000,000 b. $2,000,000/$3,000,000 c. $3,000,000/$3,000,000 d. $4,000,000/$4,000,000
e. $5,000,000/$5,000,000 f. $100,000/$300,000 (Louisiana Only)
Claims-Made Occurrence (changing from a Claims-Made to Occurrence will require the purchase of tail coverage)
9. Do you want to add, remove or make changes to a Professional Corporation or Partnership? Yes No
If Yes, please explain: ______
PART III. APPLICANT AND PRACTICE INFORMATION
10. Business structure in which you practice (check all that apply):
A Solo Practitioner in a sole proprietorship
A Partner in a Partnership
A Shareholder in a Professional Corporation
An employed orthodontist with no ownership interest
Practitioner in a LLC or LLP
Independent contractor working for another orthodontist
Affiliated with a management service organization or dental practice franchise?
Other, please explain: ______
11. Do you practice orthodontics exclusively? Yes No
If No, please explain: ______
12. Answer the following: (If Yes, to any of the questions, explain in detail on a separate page.)
THESE ARE CHANGES NOT PREVIOUSLY REPORTED
a. Have you been treated for alcoholism, narcotics addiction, mental illness or physical impairment? Yes No
b. Haveyou been the subject of any dental board action or other governmental agency? Yes No
c. Have you been the subject of any disciplinary action by a local, state or national association? Yes No
d. Have you had any state license or federal narcotic license revoked, suspended or voluntarily surrendered? Yes No
e. Have you had your membership in a professional association refused, suspended or revoked? Yes No
f. Have you been charged or convicted of any illegal acts, including DUI of alcohol or drugs Yes No
(other than minor traffic offenses)? g. Do you know of any incident, fact, circumstance, act, error or omission that may result in a professional Yes No
liability claim involving you?
h. Have you had a professional liability claim or lawsuit brought or threatened against you since the date Yes No
ofyour last application, which you have not reported to the company?
13. Do you obtain a medical and dental history on every patient entering treatment and update them throughout Yes No
treatment?
14. Do you use general anesthetic or conscious sedation? Yes No
15. a. Do you perform services at any hospital, clinic or other such facility? Yes No
If Yes, please name the facility and describe the services: ______
b. Does the facility provide you with professional liability insurance? Yes No
If Yes, at what limits? ______
16. Do you perform surgical procedures other than?
a. The removal of exfoliating deciduous teeth
b. Gingival fiberotomy
c. Maxillary midline frenectomy
d. The removal of soft tissue related unerupted or partially erupted teeth and to gingival recontouring,
e. The placement of micro implants that do not involve the reflection of a surgical flap
Yes No
If Yes, please explain: ______
PART III. (cont.) APPLICANT AND PRACTICE INFORMATION17. Do your extraoral force systems employ patient safety mechanisms? Yes No Do not use
If No, please explain: ______
18. Do you engage in any experimental procedures or administer professional services that are outside the Yes No
normal or traditional scope of orthodontic practice?
If Yes, please explain: ______
19. Please indicate the number of support personnel in your practice:
____a. Dental Hygienist _____ d. Dental Assistant _____ f. General Dentist
____ b. Orthodontist _____ e. Clerical _____ g. Lab Technician
____ c. Other (Describe) ______
20. Please describe your practice:
a. Do you have control of the staff activity? Yes No b. Do you exercise control over the staff hiring & discharge? Yes No
c. Do you have control over the treatment plans for the patients? Yes No
d. Do you have the authority to request progress records during treatment? Yes No
If No, to any of the questions, please explain: ______
21. a. Average number of patients seen per day: ______
b. Total number of active patients in treatment: ______
22. Other than on an emergency basis in your practice are multiple orthodontists treating the same patients? Yes No
23. Do you perform sleep apnea/snoring therapy: Yes No
If Yes, do your treat after a physician’s referral and the completion of a sleep study? Yes No
24. Do you perform any cosmetic dermal procedures including the use of cosmetic injectables? Yes No
If Yes, please explain: ______
PART IV. DUTIES AND OBLIGATIONS OF APPLICANT Please Read Carefully
The Applicant represents to the American Association of Orthodontists Insurance Company (a Risk Retention Group), hereafter referred to as AAOIC, that the information submitted in this Application and attachments were carefully compiled by the Applicant, or under the Applicant’s supervision, that they are true, complete, and current as of the date submitted, that theapplicant will maintain membership with the AAO as required, and that the applicant consistently utilizes the informed consent form originally provided to AAOIC.
The execution and submission of this Application shall not bind AAOIC or its agents to the issuance of insurance, nor shall it bind the Applicant to the acceptance of a policy. However, in the event a policy is issued by AAOIC and accepted by the Applicant, all of the representations in this Application shall be binding upon the Applicant.
AAOIC reserves the right to amend the terms, conditions and limitations of any policy issued as a result of this Application. In the event of any change in the information supplied on this Application, the Applicant agrees to immediately provide written notice to AAOIC.
The Applicant authorizes all former liability insurers to furnish AAOIC with all available information concerning the Applicant. The Applicant agrees that the release of such information, even if erroneous or partial, shall not result in liability to any such party. The statements and agreements made in this Application are fully incorporated into and become a part of the policy, if issued.
FRAUD WARNING NOTICE:
Any person who knowingly, and with intent to injure, defraud or deceive any insurance company, files a statement containing any false, incomplete or misleading information, is guilty of a crime.
Applicant represents that, except as indicated in the Application, the information provided by Applicant to AAOIC in Applicant’s initial Application remains true and correct as of the date of this Application.
______
Signature of Applicant Date
______
Chairman, Board of Directors Date
Return application to: AAO Insurance Company, Attn: Underwriting Department
401 N. Lindbergh Blvd.
St. Louis, Missouri 63141-7816
00 02 PL 09/12 revised