Download ® Physician Application for Financing Malpractice Insurance

Healthcare Financial Services
®
55 Union Boulevard, 2nd Floor, Totowa, NJ 07512
Toll Free: 866-661-6111 or 201-599-8841
Quick Response Fax Line: 973-956-1063
Physician Application for Financing Malpractice Insurance
PREMIUM FINANCING
Valley National Bank welcomes the opportunity to finance your malpractice insurance premium through our unique twelve-month loan designed
to maximize your practice’s cash flow. Please complete the application and return it with your premium bill to:
Valley National Bank, Healthcare Financial Services, 55 Union Boulevard, 2nd Floor, Totowa, NJ 07512
SUBMITTED TO VALLEY NATIONAL BANK FOR CREDIT RELATED TO THE FINANCING OF
MALPRACTICE INSURANCE PREMIUM. I AM ENCLOSING A COPY OF MY PREMIUM NOTICE.
I hereby apply for a loan from Valley National Bank on the terms indicated herein. I would like a loan in the amount of $_______________________
for (12) months for the 2015/2016 premium year.
oPlease deduct my application fee of $100 and the monthly payment from my Valley National Bank Account # ____________________ for an
Annual Percentage Rate (APR) of 3.75%.
o Please deduct my monthly payment from Account # _______________________ for an Annual Percentage Rate (APR) of 4.00%.
Enclosed is the $150 application fee.
Name of Bank _______________________________________________ (any continental U.S. Bank)
I hereby assign the proceeds of the loan described above to my insurance provider as listed on the enclosed premium notification and I agree
and understand that the proceeds of the loan described above will be transmitted directly to that specific insurer.
BUSINESS INFORMATION
Practice Name Address City State Zip Property is: o Owned o Leased
Medical Specialty Tax I.D. # Year Business Founded Years with Current Ownership Number of Employees Type of Business: o Corporation o Limited Liability Company o Partnership o Sole Proprietorship o Other For the Fiscal Year End of Gross Sales were $ and Net Income/Loss was $ Telephone Number Fax Number E-Mail State License # ________________________________
BUSINESS OWNERSHIP
o We intend to apply for joint credit. If applying for a joint account, or an account that you and another person will use, complete all sections
providing information about the co-applicant.
Owner #1 or Guarantor
Owner #2 or Guarantor
Name Name Title % Owned SS # Birthday Home Telephone Number Home Address City State Zip Years at Address o Own o Rent
Monthly Rent or Mortgage Payment $ Total Annual Household Income* $ Personal Net Worth (Excl. Business Assets) $ Personal Bank Name Checking Bal. $ Savings Bal. $ Title % Owned SS # Birthday Home Telephone Number Home Address City State Zip Years at Address o Own o Rent
Monthly Rent or Mortgage Payment $ Total Annual Household Income* $ Personal Net Worth (Excl. Business Assets) $ Personal Bank Name Checking Bal. $ Savings Bal. $ *Income from alimony, child support or separate maintenance need not be revealed if you do not wish to have it considered as a basis for repaying this loan.
I/We authorize and instruct any person or consumer/business reporting agency to compile and furnish to Valley National Bank (the “Bank”) any information it may
have or obtain in response to such credit inquiries and agree that same shall remain your property whether or not the credit is extended.
I/We represent to the Bank that all information set forth in this application is a true representation of facts made for the purpose of o
­ btaining the credit requested.
I/We understand that any willful misrepresentation on this application could result in the denial or termination of the requested credit or criminal action.
The Bank may request a consumer report(s) in connection with this application and subsequent consumer report(s) in connection with updating, renewing, or
extending the existing or future extensions of credit or additional information as it deems necessary. Upon my/our written request, the Bank will provide the name
and address of the consumer reporting agency furnishing reports to the Bank, if any. This offer is valid until further notice.
I/We understand and agree that all proceeds of this line or loan must be and will be used for business purposes only.
If more than one person signs this application, it is our intention to apply for joint credit.
OWNER #1 SIGNATURE
DATE
OWNER #2 or CO-APPLICANT SIGNATUREDATE
“IMPORTANT INFORMATION FOR THE ABOVE OWNER(S) ABOUT PROCEDURE FOR APPLYING FOR A LOAN - To help government fight the funding of terrorism and money laundering activities,
applicable law requires Valley National Bank (‘Valley”) to obtain, verify, and record information that identifies each person who applies for a loan. What this means for the above owner(s):
When you apply for a loan, Valley will ask your name, address, date of birth and other information that will allow Valley to identify you. Valley may also ask for other identifying documents.”
© 2015 Valley National Bank®. Member FDIC. Equal Opportunity Lender. All Rights Reserved. VCS-5917 1/15