CMF group nurse-practitioner-application fl a PDF

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NP Secure ® Malpractice Insurance For Nurse Practitioners For nearly 100 years, CM&F has partnered with the country’s strongest insurers for the most comprehensive coverages available. This Occurrence Form Insurance Policy is underwritten by America’s foremost healthcare malpractice insurer - The Medical Protective Company [MedPro], a member of the Warren Buffett/Berkshire Hathaway group of businesses. MedPro enjoys an A++ financial strength rating from the A. M. Best Company. With our combined resources and expertise, we have forged a commitment to support our clients with the challenges which they might face by providing sound protection - today, tomorrow and beyond.

Coverage Summary COVERAGES

For Fastest Coverage, Apply Online Today! www.CMFGroup.com Need Help? Have A Question About Coverage? Call Us At 1-800-221-4904 Or Email Us At [email protected]

Professional Liability

Included

Workplace/Premises Liability

Included

General Liability

Available

Good Samaritan

Included

Employment Practices Liability

Available

Assault Upon You

$25,000

First Aid

$15,000

Medical Payments

$25,000/$100,000

Deposition Fees

$10,000

License Defense

$25,000/$100,000

Sexual Misconduct

$25,000

Loss Of Earnings

$2,500 Per Day /$35,000 Aggregate

HIPAA Defense

$25,000

Biomedical Defense

$10,000

NURSE PRACTITIONERS FLORIDA

ANNUAL RATE TABLES OCCURRENCE COVERAGE

FULL TIME PRACTICE RATES (MORE THAN 10 HOURS PER WEEK) CLASS N1 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 CLASS N2 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 CLASS N3 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 CLASS N4 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 CLASS NS LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000

SELF EMPLOYED OCCURRENCE

$ $ $ $ $ $

2,665.00 2,873.00 2,955.00 3,206.00 3,998.00 4,165.00

SELF EMPLOYED OCCURRENCE

$ $ $ $ $ $

3,769.00 4,063.00 4,180.00 4,534.00 5,654.00 5,891.00

SELF EMPLOYED OCCURRENCE

$ $ $ $ $ $

4,871.00 5,251.00 5,402.00 5,860.00 7,307.00 7,613.00

SELF EMPLOYED OCCURRENCE

$ $ $ $ $ $

5,981.00 6,448.00 6,633.00 7,195.00 8,972.00 9,348.00

FULL TIME OCCURRENCE

$ $ $ $ $ $

176.00 190.00 195.00 212.00 264.00 275.00

CLASS N1 LIMIT

EMPLOYED OCCURRENCE

$ $ $ $ $ $

$100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 CLASS N2 LIMIT

EMPLOYED OCCURRENCE

$ $ $ $ $ $

$100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 CLASS N3 LIMIT

2,910.00 3,137.00 3,227.00 3,501.00 4,365.00 4,548.00

EMPLOYED OCCURRENCE

$ $ $ $ $ $

$100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000 CLASS N4 LIMIT

2,058.00 2,219.00 2,282.00 2,476.00 3,087.00 3,217.00

3,760.00 4,053.00 4,170.00 4,523.00 5,640.00 5,877.00

EMPLOYED OCCURRENCE

$100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000

$ $ $ $ $ $

4,612.00 4,972.00 5,115.00 5,548.00 6,918.00 7,209.00

Nurse Practitioner Rating Classes N1: Specializing in Dermatology, Geriatric, Women’s Health Care, Oncology, Gynecology, or Correctional Facility < 10 hours/week N2: Specializing in Psychiatric Care N3: Specializing in Family Practice, Pediatric, School Nurse, Neonatal Care N4: Specializing in Acute Critical Care, OB/GYN, Perinatal Care, Cosmetic/Aesthetic, Pain Management or Correctional Facility > 10 hours/week NS: Students currently attending an accredited Nurse Practitioner Program

NURSE PRACTITIONERS FLORIDA

ANNUAL RATE TABLES OCCURRENCE COVERAGE

PART TIME PRACTICE RATES (10 HOURS OR LESS PER WEEK) CLASS N1

SELF EMPLOYED

LIMIT

OCCURRENCE

$1,000,000 / $6,000,000

$ $ $ $ $ $

CLASS N2

SELF EMPLOYED

$100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000

LIMIT

1,333.00 1,437.00 1,478.00 1,603.00 1,999.00 2,083.00

OCCURRENCE

$1,000,000 / $6,000,000

$ $ $ $ $ $

CLASS N3

SELF EMPLOYED

$100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000

LIMIT

1,885.00 2,032.00 2,090.00 2,267.00 2,827.00 2,946.00

OCCURRENCE

$1,000,000 / $6,000,000

$ $ $ $ $ $

CLASS N4

SELF EMPLOYED

$100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000

LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000

2,436.00 2,626.00 2,701.00 2,930.00 3,654.00 3,807.00

OCCURRENCE

$ $ $ $ $ $

2,991.00 3,224.00 3,317.00 3,598.00 4,486.00 4,674.00

CLASS N1 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000

EMPLOYED OCCURRENCE

$ $ $ $ $ $

CLASS N2 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000

EMPLOYED OCCURRENCE

$ $ $ $ $ $

CLASS N3 LIMIT $100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000

$100,000 / $300,000 $200,000 / $600,000 $250,000 / $750,000 $500,000 / $1,000,000 $1,000,000 / $3,000,000 $1,000,000 / $6,000,000

1,455.00 1,569.00 1,614.00 1,751.00 2,183.00 2,274.00 EMPLOYED

OCCURRENCE

$ $ $ $ $ $

CLASS N4 LIMIT

1,029.00 1,110.00 1,141.00 1,238.00 1,544.00 1,609.00

1,880.00 2,027.00 2,085.00 2,262.00 2,820.00 2,939.00 EMPLOYED

OCCURRENCE

$ $ $ $ $ $

2,306.00 2,486.00 2,558.00 2,774.00 3,459.00 3,605.00

Nurse Practitioner Rating Classes N1: Specializing in Dermatology, Geriatric, Women’s Health Care, Oncology, Gynecology, or Correctional Facility < 10 hours/week N2: Specializing in Psychiatric Care N3: Specializing in Family Practice, Pediatric, School Nurse, Neonatal Care N4: Specializing in Acute Critical Care, OB/GYN, Perinatal Care, Cosmetic/Aesthetic, Pain Management or Correctional Facility > 10 hours/week

NURSE PRACTITIONERS FLORIDA

ANNUAL RATE TABLES CLAIMS MADE COVERAGE

FULL TIME PRACTICE RATES (MORE THAN 10 HOURS PER WEEK) CLASS N1 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N2 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N3 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N4 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000

1st Year

$ 852.00 $ 1,519.00 $ 918.00 $ 1,637.00 $ 945.00 $ 1,685.00 $ 1,025.00 $ 1,827.00 $ 1,278.00 $ 2,279.00 $ 1,332.00 $ 2,374.00

1st Year

$ $ $ $ $ $

1,205.00 1,299.00 1,336.00 1,450.00 1,808.00 1,883.00

1st Year

$ $ $ $ $ $

1,558.00 1,680.00 1,728.00 1,874.00 2,337.00 2,435.00

1st Year

$ $ $ $ $ $

1,912.00 2,061.00 2,120.00 2,300.00 2,868.00 2,988.00

EMPLOYED

SELF EMPLOYED 2nd Year 3rd Year

$ $ $ $ $ $

2,052.00 2,212.00 2,276.00 2,469.00 3,078.00 3,207.00

4th Year

$ $ $ $ $ $

2,150.00 2,318.00 2,384.00 2,586.00 3,225.00 3,360.00

$ $ $ $ $ $

2,903.00 3,129.00 3,219.00 3,492.00 4,355.00 4,537.00

4th Year

$ $ $ $ $ $

2,777.00 2,994.00 3,080.00 3,341.00 4,166.00 4,340.00

$ $ $ $ $ $

3,752.00 4,045.00 4,161.00 4,514.00 5,628.00 5,864.00

3,410.00 3,676.00 3,782.00 4,102.00 5,115.00 5,330.00

$ $ $ $ $ $

4,607.00 4,966.00 5,109.00 5,542.00 6,911.00 7,201.00

$ 658.00 $ 709.00 $ 730.00 $ 792.00 $ 987.00 $ 1,028.00

3,165.00 3,412.00 3,510.00 3,807.00 4,748.00 4,947.00

5th Year

$ $ $ $ $ $

4th Year

$ $ $ $ $ $

$ $ $ $ $ $

1,173.00 1,264.00 1,301.00 1,411.00 1,760.00 1,833.00

3rd Year

$ $ $ $ $ $

1,585.00 1,709.00 1,758.00 1,907.00 2,378.00 2,477.00

4th Year

$ $ $ $ $ $

1,727.00 1,862.00 1,915.00 2,078.00 2,591.00 2,699.00

$ $ $ $ $ $

5th Year

2,037.00 2,196.00 2,259.00 2,451.00 3,056.00 3,184.00

3,732.00 4,023.00 4,139.00 4,490.00 5,598.00 5,833.00

1st Year

$ $ $ $ $ $

931.00 1,004.00 1,032.00 1,120.00 1,397.00 1,455.00

2nd Year

$ $ $ $ $ $

1,659.00 1,788.00 1,840.00 1,996.00 2,489.00 2,593.00

3rd Year

$ $ $ $ $ $

2,241.00 2,416.00 2,485.00 2,696.00 3,362.00 3,503.00

4th Year

$ $ $ $ $ $

2,443.00 2,634.00 2,709.00 2,939.00 3,665.00 3,818.00

$ $ $ $ $ $

5th Year

2,881.00 3,106.00 3,195.00 3,466.00 4,322.00 4,503.00

4,089.00 4,408.00 4,535.00 4,919.00 6,134.00 6,391.00

5th Year

$ $ $ $ $ $

4,822.00 5,198.00 5,348.00 5,801.00 7,233.00 7,537.00

1st Year

$ $ $ $ $ $

1,202.00 1,296.00 1,333.00 1,446.00 1,803.00 1,879.00

2nd Year

$ $ $ $ $ $

2,144.00 2,311.00 2,378.00 2,579.00 3,216.00 3,351.00

3rd Year

$ $ $ $ $ $

2,896.00 3,122.00 3,212.00 3,484.00 4,344.00 4,526.00

4th Year

$ $ $ $ $ $

3,156.00 3,402.00 3,500.00 3,797.00 4,734.00 4,933.00

$ $ $ $ $ $

5th Year

3,722.00 4,012.00 4,128.00 4,478.00 5,583.00 5,817.00

EMPLOYED

SELF EMPLOYED 2nd Year 3rd Year

$ $ $ $ $ $

2,638.00 2,844.00 2,926.00 3,174.00 3,957.00 4,123.00

2nd Year

EMPLOYED

SELF EMPLOYED 2nd Year 3rd Year

$ $ $ $ $ $

$ $ $ $ $ $

1st Year

EMPLOYED

SELF EMPLOYED 2nd Year 3rd Year

$ $ $ $ $ $

2,237.00 2,411.00 2,481.00 2,691.00 3,356.00 3,496.00

5th Year

4th Year

$ $ $ $ $ $

5,021.00 5,413.00 5,568.00 6,040.00 7,532.00 7,848.00

5th Year

$ $ $ $ $ $

5,921.00 6,383.00 6,566.00 7,123.00 8,882.00 9,255.00

1st Year

$ $ $ $ $ $

1,475.00 1,590.00 1,636.00 1,774.00 2,213.00 2,305.00

2nd Year

$ $ $ $ $ $

2,630.00 2,835.00 2,917.00 3,164.00 3,945.00 4,111.00

Nurse Practitioner Rating Classes

Class N1: Specializing in Dermatology, Geriatric, Women's Health Care, Oncology, Gynecology, or Correctional Facility < 10 hours/week Class N2: Specializing in Psychiatric Care Class N3: Specializing in Family Practice, Pediatric, School Nurse, Neonatal Care Class N4: Specializing in Acute Critical Care, OB/GYN, Perinatal Care, Cosmetic/Aesthetic, Pain Management or Correctional Facility > 10 hours/week

3rd Year

$ $ $ $ $ $

3,552.00 3,829.00 3,939.00 4,273.00 5,328.00 5,552.00

4th Year

$ $ $ $ $ $

3,872.00 4,174.00 4,294.00 4,658.00 5,808.00 6,052.00

$ $ $ $ $ $

5th Year

4,566.00 4,922.00 5,064.00 5,493.00 6,849.00 7,137.00

NURSE PRACTITIONERS FLORIDA

ANNUAL RATE TABLES CLAIMS MADE COVERAGE

PART TIME PRACTICE RATES (10 HOURS OR LESS PER WEEK) CLASS N1 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N2 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N3 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000 CLASS N4 LIMIT $100,000/$300,000 $200,000/$600,000 $250,000/$750,000 $500,000/$1,000,000 $1,000,000/$3,000,000 $1,000,000/$6,000,000

1st Year

$ $ $ $ $ $

426.00 459.00 473.00 513.00 639.00 666.00

1st Year

$ $ $ $ $ $

603.00 650.00 668.00 725.00 904.00 942.00

1st Year

$ 760.00 $ $ 819.00 $ $ 843.00 $ $ 914.00 $ $ 1,140.00 $ $ 1,187.00 $

$ $ $ $ $ $

956.00 1,031.00 1,060.00 1,150.00 1,434.00 1,494.00

1,026.00 1,106.00 1,138.00 1,235.00 1,539.00 1,604.00

4th Year

$ $ $ $ $ $

$ $ $ $ $ $

1,075.00 1,159.00 1,192.00 1,293.00 1,613.00 1,680.00

$ $ $ $ $ $

1,452.00 1,565.00 1,610.00 1,746.00 2,178.00 2,269.00

$ $ $ $ $ $

1,876.00 2,023.00 2,081.00 2,257.00 2,814.00 2,932.00

$ $ $ $ $ $

1,705.00 1,838.00 1,891.00 2,051.00 2,558.00 2,665.00

$ $ $ $ $ $

2,304.00 2,483.00 2,555.00 2,771.00 3,456.00 3,601.00

1,319.00 1,422.00 1,463.00 1,587.00 1,979.00 2,062.00

1st Year

$ $ $ $ $ $

1,583.00 1,706.00 1,755.00 1,904.00 2,374.00 2,474.00

5th Year

$ $ $ $ $ $

329.00 355.00 365.00 396.00 494.00 514.00

2nd Year

$ $ $ $ $ $

587.00 632.00 651.00 706.00 880.00 917.00

3rd Year

4th Year

5th Year

$ 793.00 $ 864.00 $ 1,019.00 $ 855.00 $ 931.00 $ 1,098.00 $ 879.00 $ 958.00 $ 1,130.00 $ 954.00 $ 1,039.00 $ 1,226.00 $ 1,189.00 $ 1,296.00 $ 1,528.00 $ 1,239.00 $ 1,350.00 $ 1,592.00

1,866.00 2,012.00 2,070.00 2,245.00 2,799.00 2,917.00

1st Year

$ $ $ $ $ $

466.00 502.00 516.00 560.00 699.00 728.00

2nd Year

3rd Year

$ 830.00 $ $ 894.00 $ $ 920.00 $ $ 998.00 $ $ 1,245.00 $ $ 1,297.00 $

1,121.00 1,208.00 1,243.00 1,348.00 1,681.00 1,752.00

4th Year

$ $ $ $ $ $

1,222.00 1,317.00 1,355.00 1,470.00 1,833.00 1,909.00

$ $ $ $ $ $

5th Year

1,441.00 1,553.00 1,598.00 1,733.00 2,161.00 2,252.00

EMPLOYED 4th Year

$ $ $ $ $ $

2,045.00 2,204.00 2,268.00 2,460.00 3,067.00 3,196.00

5th Year

$ $ $ $ $ $

2,411.00 2,599.00 2,674.00 2,901.00 3,617.00 3,769.00

1st Year

$ $ $ $ $ $

601.00 648.00 667.00 723.00 902.00 940.00

2nd Year

$ $ $ $ $ $

1,072.00 1,156.00 1,189.00 1,290.00 1,608.00 1,676.00

3rd Year

$ $ $ $ $ $

1,448.00 1,561.00 1,606.00 1,742.00 2,172.00 2,263.00

4th Year

$ $ $ $ $ $

1,578.00 1,701.00 1,750.00 1,899.00 2,367.00 2,467.00

$ $ $ $ $ $

5th Year

1,861.00 2,006.00 2,064.00 2,239.00 2,792.00 2,909.00

EMPLOYED

SELF EMPLOYED 2nd Year 3rd Year

$ $ $ $ $ $

$ $ $ $ $ $

4th Year

SELF EMPLOYED 2nd Year 3rd Year

1,389.00 1,497.00 1,540.00 1,671.00 2,083.00 2,170.00

1,119.00 1,206.00 1,241.00 1,346.00 1,678.00 1,748.00

5th Year

EMPLOYED

SELF EMPLOYED 2nd Year 3rd Year

$ 779.00 $ $ 840.00 $ $ 864.00 $ $ 937.00 $ $ 1,169.00 $ $ 1,218.00 $

1st Year

EMPLOYED

SELF EMPLOYED 2nd Year 3rd Year

4th Year

$ $ $ $ $ $

2,511.00 2,707.00 2,784.00 3,020.00 3,766.00 3,924.00

$ $ $ $ $ $

5th Year

1st Year

2,961.00 3,192.00 3,283.00 3,562.00 4,441.00 4,628.00

$ 738.00 $ $ 795.00 $ $ 818.00 $ $ 887.00 $ $ 1,107.00 $ $ 1,153.00 $

2nd Year

1,315.00 1,418.00 1,459.00 1,582.00 1,973.00 2,056.00

3rd Year

$ $ $ $ $ $

Nurse Practitioner Rating Classes

Class N1: Specializing in Dermatology, Geriatric, Women's Health Care, Oncology, Gynecology, or Correctional Facility < 10 hours/week Class N2: Specializing in Psychiatric Care Class N3: Specializing in Family Practice, Pediatric, School Nurse, Neonatal Care Class N4: Specializing in Acute Critical Care, OB/GYN, Perinatal Care, Cosmetic/Aesthetic, Pain Management or Correctional Facility > 10 hours/week

1,776.00 1,915.00 1,970.00 2,137.00 2,664.00 2,776.00

4th Year

$ $ $ $ $ $

1,936.00 2,087.00 2,147.00 2,329.00 2,904.00 3,026.00

$ $ $ $ $ $

5th Year

2,283.00 2,461.00 2,532.00 2,747.00 3,425.00 3,569.00

NPSecure® Malpractice Insurance For Nurse Practitioners 1) Please print a copy of this application to your desktop printer. 2) Complete this hard copy by hand, answering all questions 3) Sign, date and either: a. Mail your completed application providing your credit card information OR with check payable to: CM&F Group, Inc., 99 Hudson Street, 12th Floor, New York, NY 10013 OR b. Fax your signed and completed application providing your credit card information (per the application) to CM&F Group, Inc. at (646) 390.5163 4) Once your application is processed & approved, your policy will be mailed within 5-7 business days. Your payment -- whether by check or credit card -- will NOT be processed until your coverage has been approved.

If previously covered with Medical Protective, please enter

Fax or Mail Completed Application To:

the policy number ________________________________

CM&F Group, Inc. 99 Hudson Street, 12th Floor New York, New York 10013-2815 (212)233-8911 (800)221-4904 Fax (646)390.5163 [email protected]

THE MEDICAL PROTECTIVE COMPANY (a Stock Company) HEALTHCARE PROFESSIONAL - PROFESSIONAL LIABILITY INSURANCE APPLICATION - NP I. General Information Please print legibly. Please answer all questions; if a question is n...