No Known or Open Claims

After diligent inquiry of my staff and employees, if applicable, I am not aware of any actual, pending or threatened claims, conduct, circumstances, incidents or disputes that could reasonably be expected to result in a claim against me, or my practice, which are not listed on my application for professional liability insurance with The Doctors Company, regardless of whether those actual, pending, or threatened claims are covered in full, in part, or not at all by insurance.

I acknowledge that the failure to disclose any actual or threatened claims which I am aware of, or which would be disclosed by reasonable inquiry, will likely void coverage for any such claim(s) under any policy(ies) of insurance which may be issued by The Doctors Company and may result in my policy(ies) being completely voided.

I acknowledge that my prior professional liability insurance is claims-made insurance and that if I cancel that policy without purchasing an extended reporting endorsement (tail coverage), there will be no coverage for any claim from any act or omission that took place during that period of claims-made coverage with my prior insurer.

I understand that I may apply to The Doctors Company for a policy with a retroactive date back to the first day of my previous claims-made policy(ies) and that, if issued, retroactive coverage would insure me for claims made against me for incidents that took place after the retroactive date and while my previous claims-made insurance was in effect, but that were not brought to my attention until after the effective date of The Doctors Company’s policy.

I further acknowledge that retroactive coverage does not and would not cover claims that have been filed against me or reported to the previous insurers prior to the effective date of the policy with The Doctors Company. I understand that any claims and all conduct, circumstances, incidents or disputes that could reasonably be expected to result in a claim must be reported to my present carrier prior to the requested effective date of any insurance with The Doctors Company and that The Doctors Company will not defend or indemnify me for any such claims and that I will have no claim against The Doctors Company for such claims.

I understand that this declaration is incorporated into and is a part of my application for insurance.