PHYSICIAN+AMS+NEW+BUSINESS+Application - Claims-Made Professional Liability Insurance Application

Sep 15, 2026

Claims-made professional liability insurance application for physicians and surgeons under Applied Medico-Legal Solutions Risk Retention Group, Inc. (AMS RRG), including an application instructions and checklist. The document outlines required responses to all questions, supporting materials such as loss run, claim worksheets, no known loss letter, declarations, curriculum vitae, licenses, extended reporting endorsements, and practice letterhead. It also explains coverage conditions and retroactive-date rules, then provides section A general demographics and initial insurance coverage fields in section B.

LanguageEnglish

CategoryForms

FormatPDF

Pages21

Reading Time7 min

AccessFree to download

APPLICATION INSTRUCTIONS & CHECKLIST

GENERAL INFORMATION – Section A

Demographics

INSURANCE COVERAGE – Section B

Policy dates and prior acts coverage

Primary practice and group information

Requested limits of liability and deductibles

CLAIMS-MADE PROFESSIONAL LIABILITY INSURANCE APPLICATION For Physicians & Surgeons APPLICATION INSTRUCTIONS & CHECKLIST We would like to thank you for taking the time to apply to Applied Medico-Legal Solutions Risk Retention Group, Inc. (AMS RRG) . You are joining physicians across the country that have helped AMS RRG grow into one of the most successful medical liability insurance risk retention groups. Below is a checklist which will help you in completing our application. 􀂅 All questions must be answered. Write in,“I do not know,” if necessary. 􀂅 The Supplemental Information Worksheet is available to provide any additional information requested, or to better explain your answers. 􀂅 A "Loss Run" from your current and prior carriers covering the last 15 years. Please complete a separate claim worksheet for each reported claim as thoroughly as possible providing a brief narrative description of each claim. 􀂅 A “No Known Loss” Letter, attached to this application. 􀂅 Please enclose a copy of the following with your application: 􀂅 Current Declarations for Professional Liability Insurance 􀂅 Curriculum Vitae 􀂅 Medical and DEA Licenses 􀂅 Purchased Extended Reporting Endorsements 􀂅 Practice letterhead for each location you practice 􀂅 Advertising material you have been using INSURANCE NOTICE Insurance coverage is subject to underwriting approval and payment of the initial premium. No coverage exists until the initial premium is received and a binder or Declarations Page, together with any applicable endorsements, has been issued to the named insured. This is an application for a claims-made policy form of professional liability insurance. The coverage of this policy is limited to liability only for those claims that: A) arise from incidents or events that happen while the policy is in force and that involve your professional services, and B) are first made against you and are reported to the company while the policy is in force. GENERAL INFORMATION – Section A | 1. Demographics | | | | | | --- | --- | --- | --- | --- | | First Name | Last Name | Middle Name | Suffix (Jr./Sr.) | Title
(MD/DO/DPM) | | | | | | | | Social Security Number | | Date of Birth | Female | Male | | - - | | / / | 􀂅 | 􀂅 | | Office Phone Number | Cell Phone Number | Home Phone Number | | --- | --- | --- | | ( ) - | ( ) - | ( ) - | | Fax Number | Practice Web Site Address | E-Mail Address | | ( ) - | | | | Primary Practice Street Address | City | State | Zip Code | County | | --- | --- | --- | --- | --- | | | | | | | | Mailing and/or Billing Street Address | City | State | Zip Code | County | | | | | | | INSURANCE COVERAGE – Section B | 1. Current Policy Expires | 2. Requested Effective Date | 3. Requested Retroactive Date | | | --- | --- | --- | --- | | / / | / / | / / | | | 4. Prior Acts Coverage (Retroactive Coverage): | | | | | a. Did you purchase an extended reporting endorsement (tail coverage) from your current carrier? | | | 􀂅 Yes 􀂅 No | | b. If NO, do you wish to purchase retroactive coverage from AMS RRG? | | | 􀂅 Yes 􀂅 No | A claims-made policy covers claims resulting from medical professional services provided or withheld on or after the retroactive date shown on the policy and first reported while the policy is in force. If your current policy or any previous policies are claims-made and you cancel the policy without purchasing an extended reporting endorsement (tail coverage) from that carrier, there will be NO COVERAGE for any claim arising from any act or omission that took place during that period of claims-made coverage. However, you may apply for a policy with a retroactive date back to the first day of your previous claims-made policy. Retroactive coverage insures claims made against you for incidents that took place while your previous claims-made insurance was in effect, but that were not brought to your attention until after the effective date of the AMS RRG policy.

FAQs

What supporting documents are required to submit this application?

The application requires a loss run for the last 15 years, a no known loss letter, and copies of current declarations, curriculum vitae, medical and DEA licenses, purchased extended reporting endorsements, and practice letterhead for each location. Additional advertising material may also be enclosed.

What does a claims-made policy cover and how does the retroactive date work?

Coverage applies only to claims arising from incidents during the policy’s in-force period that involve professional services, and that are first made against the physician and reported while the policy is in force. Retroactive coverage insures claims for incidents that occurred while prior claims-made coverage was effective but were not reported until after AMS RRG’s policy effective date.

What happens if a prior claims-made policy is canceled without purchasing tail coverage?

There is no coverage for claims arising from acts or omissions that occurred during the period of the prior claims-made coverage. The applicant may be able to apply for an AMS RRG policy with an appropriate retroactive date, subject to the policy terms and reporting requirements.

Sep 15, 2026

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