| Packet Update


General Information

Email Address:    
First Name:    
Middle Name:  
Last Name:    

Professional Liability

Since your initial application, have you been named in or had any changes in the status of a malpractice claim, suit or arbitration proceeding? 
Has any insurance carrier ever denied, cancelled, refused to renew, restrict, rate up, or place  limitation on your scope of coverage on your professional liability insurance? 


Disclosure Questions

Have any of the following ever been or are currently in the process of being investigated, denied, revoked, suspended, restricted,  limited, placed on probation, been subject to disciplinary action, reprimand, voluntary relinquishment or fined?
Clinical Privileges or Medical Staff Membership at any hospital, health care facility, clinic, etc 
 Licensed to practice in your profession 
Controlled Substance and/or DEA Registration 
Academic Appointment 
Participation in private, state, or Federal health insurance program 
Any other professional sanction 

Have you been charged and/or convicted of a felony or misdemeanor other than a traffic violation? 
Have you ever voluntarily resigned or been terminated while under investigation? 
Have you ever been disciplined by a hospital, health care facility, University, or post graduate training program? 
Are you currently or have you ever been treated for alcoholism or narcotic addiction including inpatient, outpatient or counseling? 
Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients? 
The essential function of a Locum Tenens Physician is to provide a standard of care that is acceptable within his/her specialty. Is there anything that would prevent you from performing this function with or without reasonable accommodations? 

Release of Information

The applicant declares that to the best of his/her knowledge the statements herein are true. Signing of this Application does not bind the undersigned to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy be issued, and that this Application will be attached and become part of such Policy, if issued. The insurance company and/or Delta Locum Tenens “DLT” are hereby authorized by Applicant to make any investigation and inquiry in connection with this Application, as they deem necessary, and to release information contained in the application or supplemental support documentation, (including but not limited to the application, references, background search results, etc.) to healthcare facilities which are seeking to fill its staffing needs with locum tenens healthcare providers. DLT may also share information regarding my employment with its affiliates and appropriate governmental or licensing entities. I hereby expressly release and discharge and will hold harmless DLT and the aforementioned entities, their agents, employees and/or representatives from any and all liability which might otherwise be incurred as a result of acts or omissions performed in connection with any inquiry, investigation or in the evaluation of information so received from whatever source.

It is agreed that in the event there is any material change to the answers in the questions contained herein prior to the effective date of the Policy, that I will notify DLT and, at the sole discretion of DLT, any outstanding quotations may be modified or withdrawn.

Further, I acknowledge and agree that any claims resulting from acts committed prior to the effective date of coverage are specifically excluded from coverage under this policy. I acknowledge that if I withhold information, mislead, or attempt to defraud or lie of any matter contained in this application, then such act will void the insurance policy.

The applicant shall cooperate with DLT in all respects in matters pertaining to this insurance and shall provide information, attend hearings and trials, and assist in making settlements, securing and giving evidence, obtaining the attendance of witnesses, and otherwise facilitating the conduct of any proceeding in connection with the subject matter of this insurance, as may be selected by DLT.

I agree with the statements above: