Home

 

ACORD Form 196 Medical Professional Liability Insurance App Instructions
 

 
ACORD 196 (2008/03) 1 of 11
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 05/08/2009.
Section Name Field Name Field and/or Section Description
TITLE ACORD 196 (2008/03) Medical Professional Liability Insurance The title of the form. ACORD 196, Medical Professional Liability Insurance Application, is used to apply for medical professional liability insurance coverage. The form is self-contained. It is not necessary to use ACORD 125, Commercial Insurance Application, with this application.
IDENTIFICATION SECTION Date Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Agency Address Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Enter identifier: The agency's state license number. As used here, this is required in Nebraska.
IDENTIFICATION SECTION Contact Name Enter text: The name of the individual at the producer's establishment that is the primary contact.
IDENTIFICATION SECTION Phone Enter number: The producer's contact person's phone number. If applicable, include the area code and extension.
IDENTIFICATION SECTION Fax Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION Email Address Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Code Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer.
IDENTIFICATION SECTION Sub Code Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).

ACORD 196 (2008/03) 2 of 11

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Carrier Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name.
IDENTIFICATION SECTION NAIC Code Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Applicant (First Name Insured) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Social Security # Enter identifier: The tax identifier of the named insured.
IDENTIFICATION SECTION DEA # (If Applicable) Enter identifier: The identifier for the named insured assigned by the USA Drug Enforcement Agency.
IDENTIFICATION SECTION US Citizen? Yes (Checkbox) Check the box (if applicable): Indicates the named insured is a citizen of the United States of America.
IDENTIFICATION SECTION US Citizen? No (Checkbox) Check the box (if applicable): Indicates the named insured is not a citizen of the USA.
IDENTIFICATION SECTION Date Of Birth Enter date: The date of birth of the insured.
IDENTIFICATION SECTION Primary Business Address Enter text: The first address line of the physical location.
IDENTIFICATION SECTION Enter text: The second address line of the physical location.
IDENTIFICATION SECTION Enter text: The city of the physical location.
IDENTIFICATION SECTION Enter code: The state or province of the physical location.
IDENTIFICATION SECTION Enter code: The postal code of the physical location.
IDENTIFICATION SECTION Phone Enter number: The named insured's primary phone number.
IDENTIFICATION SECTION Mailing Address Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION Enter text: The named insured's mailing address city name.

ACORD 196 (2008/03) 3 of 11

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION Enter code: The named insured's mailing address postal code.
COVERAGES/LIMITS Claims Made (Checkbox) Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis on a medical professional liability policy.
COVERAGES/LIMITS Occurrence (Checkbox) Check the box (if applicable): Indicates the "coverage trigger" is on an occurrence basis on a medical professional liability policy.
COVERAGES/LIMITS Aggregate ($) Enter limit: The liability aggregate limit amount.
COVERAGES/LIMITS Each Occurrence ($) Enter limit: The liability each occurrence limit amount.
COVERAGES/LIMITS Other ($) Enter limit: The coverage limit amount.
COVERAGES/LIMITS Other Description Enter text: The description of the coverage.
COVERAGES/LIMITS Proposed Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. As used here, this is the proposed effective date.
COVERAGES/LIMITS Proposed Retroactive Date Enter date: The retroactive date you are requesting for the policy being applied for. This is the proposed earliest date for which an occurrence could "trigger" coverage under a Claims Made policy.
PROFESSION Physician (Checkbox) Check the box (if applicable): Indicates the named insured is a physician.
PROFESSION Primary Practice Enter text: The description of the primary practice of the physician.
PROFESSION Secondary Practice Enter text: The description of the secondary practice of the physician.
PROFESSION Surgeon (Checkbox) Check the box (if applicable): Indicates the named insured is a surgeon.
PROFESSION Specialty Enter text: The description of the surgeon's specialty.
PROFESSION Other Enter text: The description of the surgeon's other practice / specialty.
PROFESSION Physician's Assistant (Checkbox) Check the box (if applicable): Indicates the named insured is a physical assistant.
PROFESSION Nurse Anesthetist (Checkbox) Check the box (if applicable): Indicates the named insured is a nurse anesthetist.
PROFESSION Surgeon's Assistant (Checkbox) Check the box (if applicable): Indicates the named insured is a surgeon assistant.
PROFESSION Psychologist (Checkbox) Check the box (if applicable): Indicates the named insured is a psychologist.
PROFESSION Nurse Midwife (Checkbox) Check the box (if applicable): Indicates the named insured is a nurse midwife.
PROFESSION Perfusionist (Checkbox) Check the box (if applicable): Indicates the named insured is a perfusionist.
PROFESSION Registered Nurse (Checkbox) Check the box (if applicable): Indicates the named insured is a registered nurse.
PROFESSION Licensed Practical Nurse (Checkbox) Check the box (if applicable): Indicates the named insured is a licensed practical nurse.
PROFESSION Optometrist (Checkbox) Check the box (if applicable): Indicates the named insured is a optometrist.
PROFESSION Emergency Medical Technician (Checkbox) Check the box (if applicable): Indicates the named insured is a emergency medical technician.

ACORD 196 (2008/03) 4 of 11

Section Name Field Name Field and/or Section Description
PROFESSION Nurse Practitioner (Checkbox) Check the box (if applicable): Indicates the named insured is a nurse practitioner.
PROFESSION Counselor (Checkbox) Check the box (if applicable): Indicates the named insured is a counselor.
PROFESSION Other (Checkbox) Check the box (if applicable): Indicates the named insured's occupation is other than those listed.
PROFESSION Other (Specify) Field Enter text: The named insured's primary occupation or business activity.
PERSONAL INFORMATION Type Of Certification Currently Held Enter text: The description of certifications held by the named insured.
PERSONAL INFORMATION State One Enter code: The state or province issuing the license.
PERSONAL INFORMATION License # One Enter identifier: The license number.
PERSONAL INFORMATION State Two Enter code: The state or province issuing the license.
PERSONAL INFORMATION License # Two Enter identifier: The license number.
PERSONAL INFORMATION State Three Enter code: The state or province issuing the license.
PERSONAL INFORMATION License # Three Enter identifier: The license number.
EDUCATION Institution One Enter text: The name of the school or educational institution.
EDUCATION Dates Of Attendance-Mo/Yr One-A Enter date: The date (MM/YYYY) the named insured started attending the school or education institution.
EDUCATION Dates Of Attendance-Mo/Yr One-B Enter date: The date (MM/YYYY) the named insured stopped attending the school or education institution.
EDUCATION Date Graduated One Enter date: The date (MM/YYYY) the named insured graduated from the school or education institution.
EDUCATION Certification Or Degree Received One Enter text: The certification or degree received.
EDUCATION Institution Two Enter text: The name of the school or educational institution.
EDUCATION Dates Of Attendance-Mo/Yr Two-A Enter date: The date (MM/YYYY) the named insured started attending the school or education institution.
EDUCATION Dates Of Attendance-Mo/Yr Two-B Enter date: The date (MM/YYYY) the named insured stopped attending the school or education institution.
EDUCATION Date Graduated Two Enter date: The date (MM/YYYY) the named insured graduated from the school or education institution.
Section Name Field Name Field and/or Section Description
EDUCATION Certification Or Degree Received Two Enter text: The certification or degree received.
EDUCATION Institution Three Enter text: The name of the school or educational institution.
EDUCATION Dates Of Attendance-Mo/Yr Three-A Enter date: The date (MM/YYYY) the named insured started attending the school or education institution.
EDUCATION Dates Of Attendance-Mo/Yr Three-B Enter date: The date (MM/YYYY) the named insured stopped attending the school or education institution.
EDUCATION Date Graduated Three Enter date: The date (MM/YYYY) the named insured graduated from the school or education institution.
EDUCATION Certification Or Degree Received Three Enter text: The certification or degree received.
EDUCATION List Continuing Education Courses And Credits Received Within Last 2 Years (Or Attach Copies Of Certificates And/Or Credits Received) Enter text: The description of continuing education courses and credits received within the stated number of years.
EDUCATION Has Your Certification/License In Any State Ever Been (Voluntarily Or Otherwise) Suspended, Denied, Revoked, Restricted Or Limited In Any Way? If Yes, Explain-YES (Checkbox) Check the box (if applicable): Indicates a "Yes" response to the question, "Has your certification / license in any state ever been (voluntarily or otherwise) suspended, denied, revoked, restricted or limited in any way?".
EDUCATION Has Your Certification/License In Any State Ever Been (Voluntarily Or Otherwise) Suspended, Denied, Revoked, Restricted Or Limited In Any Way? If Yes, Explain-NO (Checkbox) Check the box (if applicable): Indicates a "No" response to the question, "Has your certification / license in any state ever been (voluntarily or otherwise) suspended, denied, revoked, restricted or limited in any way?".

ACORD 196 (2008/03) 5 of 11

ACORD 196 (2008/03) 6 of 11

Section Name Field Name Field and/or Section Description
EDUCATION Has Your Certification/License In Any State Ever Been (Voluntarily Or Otherwise) Suspended, Denied, Revoked, Restricted Or Limited In Any Way? If Yes, Explain-Other Field Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
EDUCATION Current Practice (Describe General Duties And Extent Of Supervision (If Any) Enter text: The description of the current practice including general duties and extent of supervision (if any).
EDUCATION List Any Association/Society/Memberships Related To Your Profession Enter text: The name of the affiliated organization.
EDUCATION Enter text: The name of the affiliated organization.
EDUCATION Enter text: The name of the affiliated organization.
EDUCATION Enter text: The name of the affiliated organization.
EDUCATION Enter text: The name of the affiliated organization.
EDUCATION Present Employees And Positions Enter text: The full name of the employee.
EDUCATION Enter text: The title this person has in the current employment position.
EDUCATION Enter text: The full name of the employee.
EDUCATION Enter text: The title this person has in the current employment position.
EDUCATION Enter text: The full name of the employee.
EDUCATION Enter text: The title this person has in the current employment position.
EDUCATION Enter text: The full name of the employee.
EDUCATION Enter text: The title this person has in the current employment position.
EDUCATION Enter text: The full name of the employee.
EDUCATION Enter text: The title this person has in the current employment position.
LOSS HISTORY Chk Here If None (Checkbox) Check the box (if applicable): Indicates there are no prior losses or occurrences that may give rise to claims for the mandated number of years.
LOSS HISTORY See Attached Loss Summary (Checkbox) Check the box (if applicable): Indicates that a loss summary report is attached to the policy.
LOSS HISTORY Date Of Occurrence One Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Type/Description Of Occurrence Or Claim One Enter text: A brief description of the loss.

ACORD 196 (2008/03) 7 of 11

Section Name Field Name Field and/or Section Description
LOSS HISTORY Date Of Claim One Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid One Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved One Enter amount: The reserve amount the previous carrier is holding open for this claim.
Claim Status-Open (Checkbox)
LOSS HISTORY One Check the box (if applicable): Indicates the claim is still open.
Claim Status-Closed (Checkbox)
LOSS HISTORY One Check the box (if applicable): Indicates the claim is closed.
Enter date: The date when the accident or incident occurred that resulted in the filing of a
LOSS HISTORY Date Of Occurrence Two claim.
Type/Description Of Occurrence
LOSS HISTORY Or Claim Two Enter text: A brief description of the loss.
LOSS HISTORY Date Of Claim Two Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Two Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Two Enter amount: The reserve amount the previous carrier is holding open for this claim.
Claim Status-Open (Checkbox)
LOSS HISTORY Two Check the box (if applicable): Indicates the claim is still open.
Claim Status-Closed (Checkbox)
LOSS HISTORY Two Check the box (if applicable): Indicates the claim is closed.
Enter date: The date when the accident or incident occurred that resulted in the filing of a
LOSS HISTORY Date Of Occurrence Three claim.
Type/Description Of Occurrence
LOSS HISTORY Or Claim Three Enter text: A brief description of the loss.
LOSS HISTORY Date Of Claim Three Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Three Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Three Enter amount: The reserve amount the previous carrier is holding open for this claim.
Claim Status-Open (Checkbox)
LOSS HISTORY Three Check the box (if applicable): Indicates the claim is still open.
Claim Status-Closed (Checkbox)
LOSS HISTORY Three Check the box (if applicable): Indicates the claim is closed.
Enter identifier: The customer's identification number assigned by the producer (e.g.
IDENTIFICATION SECTION Agency Customer ID agency or brokerage).
PRIOR CARRIER
INFORMATION Carrier One Enter text: The name of the previous insurer.
PRIOR CARRIER
INFORMATION Policy Number One Enter identifier: The policy number of the previous coverage.

ACORD 196 (2008/03) 8 of 11

Section Name Field Name Field and/or Section Description
PRIOR CARRIER Policy Type-Claims Made Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis
INFORMATION (Checkbox) One on a medical professional liability policy.
PRIOR CARRIER Policy Type-Occurrence Check the box (if applicable): Indicates the "coverage trigger" is on an occurrence basis
INFORMATION (Checkbox) One on a medical professional liability policy.
PRIOR CARRIER Enter date: The retroactive date for the policy being described. This is the date for which
INFORMATION Retro Date One an occurrence could "trigger" coverage under a Claims Made policy.
PRIOR CARRIER
INFORMATION Eff-Exp Date One Enter date: The effective date of the prior policy.
PRIOR CARRIER
INFORMATION Eff-Exp Date One Enter date: The expiration date of the previous coverage.
PRIOR CARRIER
INFORMATION General Aggregate One Enter limit: The liability aggregate limit amount.
PRIOR CARRIER
INFORMATION Each Occurrence One Enter limit: The liability each occurrence limit amount.
PRIOR CARRIER
INFORMATION Carrier Two Enter text: The name of the previous insurer.
PRIOR CARRIER
INFORMATION Policy Number Two Enter identifier: The policy number of the previous coverage.
PRIOR CARRIER Policy Type-Claims Made Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis
INFORMATION (Checkbox) Two on a medical professional liability policy.
PRIOR CARRIER Policy Type-Occurrence Check the box (if applicable): Indicates the "coverage trigger" is on an occurrence basis
INFORMATION (Checkbox) Two on a medical professional liability policy.
PRIOR CARRIER Enter date: The retroactive date for the policy being described. This is the date for which
INFORMATION Retro Date Two an occurrence could "trigger" coverage under a Claims Made policy.
PRIOR CARRIER
INFORMATION Eff-Exp Date Two Enter date: The effective date of the prior policy.
PRIOR CARRIER
INFORMATION Eff-Exp Date Two Enter date: The expiration date of the previous coverage.
PRIOR CARRIER
INFORMATION General Aggregate Two Enter limit: The liability aggregate limit amount.
PRIOR CARRIER
INFORMATION Each Occurrence Two Enter limit: The liability each occurrence limit amount.
PRIOR CARRIER
INFORMATION Carrier Three Enter text: The name of the previous insurer.
PRIOR CARRIER
INFORMATION Policy Number Three Enter identifier: The policy number of the previous coverage.

ACORD 196 (2008/03) 9 of 11

Section Name Field Name Field and/or Section Description
PRIOR CARRIER Policy Type-Claims Made Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis
INFORMATION (Checkbox) Three on a medical professional liability policy.
PRIOR CARRIER Policy Type-Occurrence Check the box (if applicable): Indicates the "coverage trigger" is on an occurrence basis
INFORMATION (Checkbox) Three on a medical professional liability policy.
PRIOR CARRIER Enter date: The retroactive date for the policy being described. This is the date for which
INFORMATION Retro Date Three an occurrence could "trigger" coverage under a Claims Made policy.
PRIOR CARRIER
INFORMATION Eff-Exp Date Three Enter date: The effective date of the prior policy.
PRIOR CARRIER
INFORMATION Eff-Exp Date Three Enter date: The expiration date of the previous coverage.
PRIOR CARRIER
INFORMATION General Aggregate Three Enter limit: The liability aggregate limit amount.
PRIOR CARRIER
INFORMATION Each Occurrence Three Enter limit: The liability each occurrence limit amount.
PRIOR CARRIER
INFORMATION Carrier Four Enter text: The name of the previous insurer.
PRIOR CARRIER
INFORMATION Policy Number Four Enter identifier: The policy number of the previous coverage.
PRIOR CARRIER Policy Type-Claims Made Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis
INFORMATION (Checkbox) Four on a medical professional liability policy.
PRIOR CARRIER Policy Type-Occurrence Check the box (if applicable): Indicates the "coverage trigger" is on an occurrence basis
INFORMATION (Checkbox) Four on a medical professional liability policy.
PRIOR CARRIER Enter date: The retroactive date for the policy being described. This is the date for which
INFORMATION Retro Date Four an occurrence could "trigger" coverage under a Claims Made policy.
PRIOR CARRIER
INFORMATION Eff-Exp Date Four Enter date: The effective date of the prior policy.
PRIOR CARRIER
INFORMATION Eff-Exp Date Four Enter date: The expiration date of the previous coverage.
PRIOR CARRIER
INFORMATION General Aggregate Four Enter limit: The liability aggregate limit amount.
PRIOR CARRIER
INFORMATION Each Occurrence Four Enter limit: The liability each occurrence limit amount.
GENERAL INFORMATION Have You Ever Been Insured By Mutual Assurance Or Medical Assurance For Professional Liability? Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to, "Have you ever been insured by mutual assurance or medical assurance for professional liability?".

ACORD 196 (2008/03) 10 of 11

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Policy Number Enter identifier: The policy number of the previous coverage.
GENERAL INFORMATION Previous Employer Enter text: The employer name (business name if self-employed). As used here, this is the previous employer name.
GENERAL INFORMATION If professional liability coverage is provided through your employer, do you maintain a separate policy for professional liability? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do you maintain a separate policy for professional liability?".
GENERAL INFORMATION Have You Ever Been Diagnosed With Or Professionally Advised To Seek Treatment For Alcohol/Drug Abuse Or Addiction, Mental Illness Or Chronic Physical Illness? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever been diagnosed with or professionally advised to seek treatment for alcohol / drug abuse or addiction, mental illness or chronic physical illness?".
GENERAL INFORMATION Have You Ever Been Diagnosed With Or Professionally Advised To Seek Treatment For Alcohol/Drug Abuse Or Addiction, Mental Illness Or Chronic Physical Illness? -Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Have any fee or professional relation complaints been registered against you with your professional association(s), hospital(s) or any state licensing authority? Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to, "Have any fee or professional relation complaints been registered against you with your professional association(s), hospital(s) or any state licensing authority?".
GENERAL INFORMATION Have any fee or professional relation complaints been registered against you with your professional association(s), hospital(s) or any state licensing authority? - Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Have You Ever Been Charged With Or Convicted Of A Criminal Offense? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever been charged with or convicted of a criminal offense?".

ACORD 196 (2008/03) 11 of 11

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Have You Ever Been Charged With Or Convicted Of A Criminal Offense? - Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Has Your Professional Liability Insurance Ever Been Canceled, Suspended, Non-Renewed, Declined Or Issued Only On Special Terms? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has your professional liability insurance ever been cancelled, suspended, non-renewed, declined or issued only on special terms?".
GENERAL INFORMATION Has Your Professional Liability Insurance Ever Been Canceled, Suspended, Non-Renewed, Declined Or Issued Only On Special Terms? - Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Are You A Subsidiary Of Another Entity Or Do You Have Any Subsidiary? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are you a subsidiary of another entity or do you have any subsidiaries?".
GENERAL INFORMATION Are You A Subsidiary Of Another Entity Or Do You Have Any Subsidiary? - Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
SIGNATURE Producers Signature Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states.
SIGNATURE Producer's Name Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form.
SIGNATURE State Producer License No Enter identifier: The State License Number of the producer.
SIGNATURE Applicant Signature Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE Date Enter date: The date the form was signed by the named insured.
SIGNATURE National Producer Number Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).