Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 15

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SECTION 5: COMPREHENSIVE LIABILITY INSURANCE INFORMATION
As required in 42 C.F.R. section 424.57(c)(10), all DMEPOS suppliers must have comprehensive liability
insurance in the amount of at least $300,000 (for each incident) and the insurance must remain in force at all
times. The NSC MAC, with full mailing address as shown on page 3, must be listed on the policy as a certificate
holder. You must submit a copy of the liability insurance policy or evidence of self-insurance with this
application. Failure to maintain the required insurance at all times will result in revocation of your Medicare
supplier billing number retroactive to the date the insurance lapsed, and/or overpayment collection.
Malpractice insurance is not the same as comprehensive liability insurance and does not meet compliance for
this requirement.
If you are changing your comprehensive liability insurance information, check the box below and furnish the
effective date.
Change
Effective Date (mm/dd/yyyy):
Name of Insurance Company
Insurance Policy Number
Date Policy Issued (mm/dd/yyyy)
Expiration Date of Policy (mm/dd/yyyy)
Insurance Agent’s First Name
Middle Initial
Last Name
Jr., Sr., M.D., etc.
Agent’s Telephone Number
Agent’s Fax Number (if applicable)
Agent’s E-mail Address (if applicable)
Underwriter’s Company Name
Underwriter’s Telephone Number
Underwriter’s Fax Number (if applicable)
Underwriter’s E-mail Address (if applicable)
SECTION 6: SURETY BOND INFORMATION
As required in 42 C.F.R. section 424.57(d), DMEPOS suppliers who are required to obtain a surety bond must
complete this section. Furnish all requested information about the surety bond company and the surety bond.
Submit a copy of the original surety bond, signed by a Delegated or Authorized Official, with this application.
Check here if this supplier is not required to obtain a surety bond and skip to Section 7.
A. NAME AND ADDRESS OF SURETY BOND COMPANY
If you are changing your surety bond information, check the box below and furnish the effective date.
Change
Effective Date (mm/dd/yyyy):
Legal Business Name of Surety Bond Company as Reported to the IRS
Tax Identification Number
Business Address Line 1 (Street Name and Number)
Business Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
B. SURETY BOND INFORMATION
Change
Effective Date (mm/dd/yyyy):
Amount of Surety Bond
Surety Bond Number
$
Effective Date of Surety Bond (mm/dd/yyyy)
If reporting a new bond, give cancellation date of the current bond (mm/dd/yyyy)
CMS-855S (05/16)
14

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