DEPARTMENT OF INSURANCE
May 29, 2007
Bulletin 148
Indiana Patient's Compensation Fund - Filings
This Bulletin is directed to all insurers that provide coverage to health care providers under Indiana's Medical Malpractice Act. Portions of Bulletin 119 relating to the Certificate of Insurance are hereby withdrawn and replaced by this Bulletin 148. All other provisions of Bulletin 119 remain in effect.
Pursuant to IC 34-18-3-2, a health care provider may qualify under the Indiana Medical Malpractice Act by filing with the Department of Insurance proof of financial responsibility and payment of a surcharge to the Indiana Patient's Compensation Fund. Attached to this Bulletin as Exhibit A is the certificate that shall be used when filing proof of financial responsibility with the Patient's Compensation Fund on or after July 1, 2007.
INDIANA DEPARTMENT OF INSURANCE
________________________________
James Atterholt, Commissioner
EXHIBIT A
CERTIFICATE OF INSURANCE
| | | | | |
| TO: | INDIANA PATIENT'S COMPENSATION FUND | | | Surcharge | Effective Date |
| | MEDICAL MALPRACTICE DIVISION | Cancellation: |  | $________ | __________ |
| | 311 W. WASHINGTON ST. STE.300 | Return Surcharge | | $________ | __________ |
| | INDIANAPOLIS, IN 46204-2787 | Additional Surcharge | | $________ | __________ |
| | | Surcharge Change Reason:_______________________ |
| | | _______________________________________ |
| | | | | | | | | | | | |
| | | | | | | | | | | | | |
| Health Care Provider: | Medical License No. (Individual): |
| | |
| | EIN# (Entity): |
| | Please do not provide individual Social Security number |
| Address (Street, City, State, Zip): | County of Service: |
| | |
| Policy No.: | Occurrence | | Retro Date | Including employees |
| | Claims Made | | (CM or RP ) | |
| | Reporting Endors. | | | Excluding employees |
| Coverage Dates: | ISO | | Date Surcharge | |
| From: _______________ To: ________________ | Code: | | Rec'd from Provider: | |
| | | | | |
| Limits of Liability: | Premium: | Surcharge: | Under 90 day | Over 90 Day |
| | (IN P/L Only) | | Penalty: | Penalty: |
| $______ | per occurrence | $_____ | annual aggregate | | | | |
| The following credits are only available for health care providers identified under Rule 60: |
| Credits: | Part-Time | | Medical | Newly Licensed | Fellowship |
| | Credits | | School | Physicians | Full-Time 50% |
| (Only one | 0-12 hrs. 75% | Faculty | 1st yr. 50% | Greater of: |
| credit may | 13-25 hrs. 50% | 67% | 2nd yr. 25% | Full-time surcharge for medical practice outside fellowship |
| be applied) | 26-30 hrs. 25% | Retired | | 50% of surcharge due for specialty class of fellowship |
| Insurance Carrier Name: | NAIC# |
| | |
| Contact Name: | Telephone Number/E-mail: |
| | |
| The undersigned Insurance Company/Broker, hereby certifies limits of liability on behalf of the above referenced Health Care Provider of not less than Two Hundred and Fifty Thousand ($250,000) Dollars for each occurrence and with an annual aggregate of Seven Hundred and Fifty Thousand ($750,000) Dollars as required, unless otherwise mandated by statute, for claims against said Health Care Provider as a result of Medical Malpractice, or allegation thereof, within the State of Indiana, and further that said policy of insurance complies in all respects with the provisions of the Indiana Patient's Compensation Act Indiana Code 34-18-1-1 et seq. |
| |
| It is further certified that the surcharge for the above referenced coverage for the period specified in this policy is at the appropriate Class rate for the named specialty, is based upon the published calculation for a hospital or nursing home, or is One Hundred and Ten Percent (110%) of the premium for non-physician, non-hospital or non-nursing home providers. Said Company/Broker also agrees to collect and remit the rated surcharge or a minimum surcharge of one hundred ($100.00) dollars, whichever is larger, for each year of the period of coverage to the Department of Insurance, Patient's Compensation Fund, State of Indiana, within thirty (30) days of receipt but not more than sixty (60) days from the effective date of said policy. |
| |
| It is further acknowledged that in the event of termination of the policy herein certified, or any reduction of liability limit, such termination or change shall not be effective unless notice of same has been delivered to the Department of Insurance, State of Indiana, not less than thirty (30) days prior to such change. Notice shall be considered to have been given upon placing same in the United States Mail by First Class Certified Mail, a copy of which shall have been mailed to the health care provider. |
| |
| Dated this ____ day of _________________, 20___ at the insurance office of ____________________________ |
| |
| | | Signed by: ______________________________________ |
| | | | Authorized Signature |
| | | Printed: ________________________________________ |
| | | Title: __________________________________________ |
Posted: 04/23/2008 by Legislative Services Agency
DIN: 20080423-IR-760080283NRA
Composed: Apr 27,2024 1:39:44PM EDT
A PDF version of this document.
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