Sample Forms and Documents
This page will include sample documents, contracts, reports that you may find useful. We will update this page as time goes on. If something is not here that you are interested in, please let us know.
Sample Budget - The budget is one of the most important pieces of rating for the insurance carriers. Without proper information, the underwriters will have to guess for rating. This will never work out in your favor. Below is a link to a sample budget and a version of what I prepare for every client. The most important features are: historical and projected data, break out between "corporate" exposure (this includes government work where FTCA applies, situations where the provider supplies their own insurance, you co broker a placement with another agency and they are providing the malpractice), and a break out of the "higher risk" territories (for example, at a minimum, I usually break out which placements are in Cook County Illinois versus the rest of Illinois, the 5 burroughs of NY, South Florida, Las Vegas, etc...see Sample Territory List.
Sample Provider Contract - Coming Soon.
Sample Client Contract - Coming Soon.
Sample Loss Run - A "loss run" is a history of your claims experience. It usually includes the date of treatment, the date the claim was filed, the date the claim closed, the claim status, a brief narrative of the events and the reserves costs associated with the claims. These reserves and costs are usually broken out into four categories: Indemnity Reserve, Expense Reserve, Indemnity Paid and Expense Paid. The reserves are the amount the insurance carrier expects the claim still to spend. The Paid amounts are what they have paid thus far. That being the case, only open claims will have reserves.
Sample Audit Illustration - Please see Malpractice Audit.
Compensation Fund Summary - Compensation Funds can be fairly daunting. For the most part, your broker or insurance carrier should be taking care of these for you. However, I did want to point out the summary of the main funds so you can be prepared on which states will require additional monies in order to do business.
Sample Territory List - This includes how one of the larger professional liability carriers ranks each territory from "low risk" to "high risk". On this example, Territory 1 are the lower risk territories and Territory 4 are the higher risk territories. Please note, all carriers do not use the same territory lists.
Sample "IBNR" Letter - If you have a claims made policy, you likely get many requests from providers asking if they need a "tail" when they leave and how they can be assured they have coverage after they are no longer contracted with you. Attached is the letter I normally use for their records. For what it's worth, I field many of these calls and my usual explanation is: "We are covered by a claims made policy that includes coverage for all patients seen and providers contracted back to our retroactive date of XXXX for as long as we have a policy in force. In the event we don't have a policy in force, our contracts with our clients and facilities require us to purchase a tail that will cover all of our contracted providers and patients seen back to our retroactive date".