Form 2713r5 - Certificate Of Insurance printable pdf download

Form 2713r5 - Certificate Of Insurance

CERTIFICATE OF INSURANCE

TO:INDIANA PATIENT’S COMPENSATION FUND

MEDICAL MALPRACTICE DIVISION

311 W. WASHINGTON ST. STE.300

INDIANAPOLIS, IN 46204-2787

RE: POLICY #

POLICY TYPE:

BASIC LICENSE#

HEALTH CARE PROVIDER:

(INCLUDING-EXCLUDING) EMPLOYEES

ADDRESS:

City

County

State

Zip

COVERAGE DATE

TO:

LIMITS OF LIABILITY

PER OCCURRENCE

ANNUAL AGGREGATE

SURCHARGE AMOUNT PAID:

The undersigned Insurance Company, hereby certifies limits of liability on behalf of the above

referenced Health Care Provider of not less the One Hundred Thousand ($100,000) Dollars for

each occurrence and not less than its annual aggregate as required 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 now know as Public Law 111, Acts 1998.

It is further certified that the premium for the above referenced coverage for the period specified

in this policy is $

And said Company agrees to collect and remit an

additional One hundred fifty percent (150%) of said premium amount or a minimum surcharge

of one hundred ($100.00) dollars for each year of the period of coverage, whichever is larger, to

the Department of Insurance, Patient’s Compensation Fund, State of Indiana, within ninety (90)

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 Mail, a copy of which shall have been mailed to

the health care provider.

DATED THIS

DAY OF

, 19 .

AT THE

OFFICE OF

INSURANCE COMPANY.

SIGNED BY:

Pac-3/State Form 2713R5

(Authorized Representive)

Form 2713r5 - Certificate Of Insurance

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