Download 20. Please describe your practice

PROFESSIONAL LIABILITY INSURANCE RENEWAL APPLICATION
AAO INSURANCE COMPANY, A Risk Retention Group
This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your
State. State insurance insolvency guaranty funds are not available for your risk retention group.
Home office: Scottsdale, AZ
If you have any questions, please call 800-240-2650.
APPLICANT INSTRUCTIONS
A. All questions must be answered completely. Please type or print clearly in ink.
B. The application and all supplemental forms must be signed in ink and dated by the applicant.
Part I.
GENERAL POLICY INFORMATION
Please indicate any changes in the policy information
Policy Number:
Current Policy Limits:
Policy Type:
Name:
1. Primary Office Location
Street
Total practice hours per
week in this office:
City
County
State
Required!
Zip
Name of Corporation, Partnership insured under this policy:
Primary Office Phone Number
Primary Fax Number
Primary Office Business Manager Contact:
2. Secondary Office Location
Street
Total practice hours per
week in this office:
City
County
Secondary Office Phone Number
State
Secondary Fax Number
Required!
Zip
Secondary Office Business Manager Contact
3. Additional Office Locations (if more than 3 office locations, please attach separate page)
Street
4. Mailing Address:
Other:
City
1.  Primary Location
5. Additional Dental License Information:
State:
License #:
State:
License #:
State
Zip Code
2.  Secondary Location
Total practice
hours per week
in this office:
Required!
E-Mail Address:
Date Licensed:
Date Licensed:
Expiration Date:
Expiration Date:
6. a. Do you teach or supervise students in any graduate orthodontic program?
Yes  No 
If Yes, please indicate which program: ___________________________________________________________________
If Yes, are you full-time faculty _______ or part-time faculty _______?
b. Does this program provide you with professional liability insurance for your clinical supervision of students?
Yes  No 
c. If No, are you requesting coverage for clinical supervision of students?
If you are requesting insurance, list the address above or on a separate page.
Yes  No 
PART II.
POLICY CHANGES
*COMPLETE ONLY IF CHANGING COVERAGE*
7. Are you seeking part-time coverage (consistently practicing less than 20 hours total per week in all locations)?
Yes  No 
8. Change coverage to: (occurrence/aggregate)
a.  $1,000,000/$3,000,000
e.  $5,000,000/$5,000,000
Claims-Made 
b.  $2,000,000/$3,000,000 c.  $3,000,000/$3,000,000 d.  $4,000,000/$4,000,000
f.  $100,000/$300,000 (Louisiana Only)
Occurrence 
(changing from a Claims-Made to Occurrence will require the purchase of tail coverage)
9. Do you want to add, remove or make changes to a Professional Corporation or Partnership?
Yes  No 
If Yes, please explain: ____________________________________________________________________________________
PART III.
APPLICANT AND PRACTICE INFORMATION
10. Business structure in which you practice (check all that apply):
 A Solo Practitioner in a sole proprietorship
 A Partner in a Partnership
 A Shareholder in a Professional Corporation
 An employed orthodontist with no ownership interest
 Practitioner in a LLC or LLP
 Independent contractor working for another orthodontist
 Affiliated with a management service organization or dental practice franchise?
 Other, please explain: _________________________________________________________________________________
11. Do you practice orthodontics exclusively?
Yes  No 
If No, please explain: ___________________________________________________________________________________
12. Answer the following: (If Yes, to any of the questions, explain in detail on a separate page.)
THESE ARE CHANGES NOT PREVIOUSLY REPORTED
a. Have you been treated for alcoholism, narcotics addiction, mental illness or physical impairment?
b. Have you been the subject of any dental board action or other governmental agency?
c. Have you been the subject of any disciplinary action by a local, state or national association?
d. Have you had any state license or federal narcotic license revoked, suspended or voluntarily surrendered?
e. Have you had your membership in a professional association refused, suspended or revoked?
f. Have you been charged or convicted of any illegal acts, including DUI of alcohol or drugs
(other than minor traffic offenses)?
g. Do you know of any incident, fact, circumstance, act, error or omission that may result in a professional
liability claim involving you?
h. Have you had a professional liability claim or lawsuit brought or threatened against you since the date
of your last application, which you have not reported to the company?
Yes
Yes
Yes
Yes
Yes
Yes






No
No
No
No
No
No






Yes  No 
Yes  No 
13. Do you obtain a medical and dental history on every patient entering treatment and update them throughout
Yes  No 
treatment?
14. Do you use general anesthetic or conscious sedation?
Yes  No 
15. a. Do you perform services at any hospital, clinic or other such facility?
Yes  No 
If Yes, please name the facility and describe the services: ______________________________________________________
b. Does the facility provide you with professional liability insurance?
If Yes, at what limits? _________________________________________________
Yes  No 
16. Do you perform surgical procedures other than?
a. The removal of exfoliating deciduous teeth
b. Gingival fiberotomy
c. Maxillary midline frenectomy
d. The removal of soft tissue related unerupted or partially erupted teeth and to gingival recontouring,
e. The placement of micro implants that do not involve the reflection of a surgical flap
Yes  No 
If Yes, please explain: _________________________________________________________________________________
PART III. (cont.)
APPLICANT AND PRACTICE INFORMATION
17. Do your extraoral force systems employ patient safety mechanisms?
Yes  No  Do not use 
If No, please explain: ______________________________________________________________________________________
18. Do you engage in any experimental procedures or administer professional services that are outside the
Yes  No 
normal or traditional scope of orthodontic practice?
If Yes, please explain: ______________________________________________________________________________________________
19. Please indicate the number of support personnel in your practice:
____a. Dental Hygienist
_____ d. Dental Assistant
____ b. Orthodontist
_____ e. Clerical
____ c. Other (Describe) ____________________________________
_____ f. General Dentist
_____ g. Lab Technician
20. Please describe your practice:
a. Do you have control of the staff activity?
Yes  No 
b. Do you exercise control over the staff hiring & discharge?
Yes  No 
c. Do you have control over the treatment plans for the patients?
Yes  No 
d. Do you have the authority to request progress records during treatment?
Yes  No 
If No, to any of the questions, please explain: _________________________________________________________________
21. a. Average number of patients seen per day:
_______
b. Total number of active patients in treatment: _______
22. Other than on an emergency basis in your practice are multiple orthodontists treating the same patients?
Yes  No 
23. Do you perform sleep apnea/snoring therapy:
If Yes, do your treat after a physician’s referral and the completion of a sleep study?
Yes  No 
Yes  No 
24. Do you perform any cosmetic dermal procedures including the use of cosmetic injectables?
Yes  No 
If Yes, please explain: ____________________________________________________________________________________
PART IV.
DUTIES AND OBLIGATIONS OF APPLICANT Please Read Carefully
The Applicant represents to the American Association of Orthodontists Insurance Company (a Risk Retention Group), hereafter referred to as AAOIC, that the
information submitted in this Application and attachments were carefully compiled by the Applicant, or under the Applicant’s supervision, that they are true, complete,
and current as of the date submitted, that the applicant will maintain membership with the AAO as required, and that the applicant consistently utilizes the
informed consent form originally provided to AAOIC.
The execution and submission of this Application shall not bind AAOIC or its agents to the issuance of insurance, nor shall it bind the Applicant to the acceptance of a
policy. However, in the event a policy is issued by AAOIC and accepted by the Applicant, all of the representations in this Application shall be binding upon the
Applicant.
AAOIC reserves the right to amend the terms, conditions and limitations of any policy issued as a result of this Application. In the event of any change in the
information supplied on this Application, the Applicant agrees to immediately provide written notice to AAOIC.
The Applicant authorizes all former liability insurers to furnish AAOIC with all available information concerning the Applicant. The Applicant agrees that the release of
such information, even if erroneous or partial, shall not result in liability to any such party. The statements and agreements made in this Application are fully
incorporated into and become a part of the policy, if issued.
FRAUD WARNING NOTICE:
Any person who knowingly, and with intent to injure, defraud or deceive any insurance company, files a statement containing any false, incomplete or misleading
information, is guilty of a crime.
Applicant represents that, except as indicated in the Application, the information provided by Applicant to AAOIC in Applicant’s initial Application remains true and
correct as of the date of this Application.
___________________________________________________
Signature of Applicant
__________________________
Date
__________________________
Chairman, Board of Directors
Date
Return application to:
AAO Insurance Company, Attn: Underwriting Department
401 N. Lindbergh Blvd.
St. Louis, Missouri 63141-7816
00 02 PL 09/12 revised