LOUISIANA PATIENT’S COMPENSATION FUND GROUP APPLICATION
(FOR FTE's, Locum Tenens, Clinics, ER Groups, Surgical Centers with PRIMARY INSURANCE)

Required field notice: Fields marked "Required" must be completed.

PROVIDER DETAILS

***Complete Name & Mailing Address

License #

Street/Mailing Address Line 1

Date of Birth

Street/Mailing Address Line 2

Professional Specialty

City, State Zip Code

PCF Code

Phone #

If advanced practice nurse, name of supervising MD:

PRIMARY COVERAGE -- The COI or declarations page from the insurer's policy is required.

Insuring Company

Policy #

Effective From

Retro Date (if applicable)***

Policy Form

Claims Made*** OR Occurrence

Primary Premium

PCF Surcharge

Professional Liability Limits

Each Claim / Aggregate

If Locum Tenens, what physician are you covering for:

Hospitals you service:

NUMBER OF OUTPATIENT VISITS/DRAWS/PROCEDURES:

TYPE OF FTE'S	NUMBER OF FTE'S	NUMBER OF HOURS -- PER WEEK

Must advise the PCF of any offsite entities or multiple locations for which coverage is provided along with the address for each location and proof of underlying coverage.

Employees as Additional Insureds:

Please see below inclusions/exclusions; complete the proper form and include proof of underlying coverage.

INCLUSIONS: Employed allied healthcare providers.

EXCLUSIONS: This does not include those who require a PCF surcharge, such as, NP•s, PA•s, CNS•, CRNA•s, etc.

PCF RESERVES THE RIGHT TO DENY COVERAGE FOR THE FOLLOWING:

Injury arising out of a criminal act, including but not limited to sexual abuse or molestation, fraud committed by the insured or any person for whom the insured is legally responsible, and battery.
Third (3rd) party claims filed by an injured party that was not a patient of the health care provider.
Services or treatment rendered as a licensed provider in states other than Louisiana, even if the underlying insurer provides coverage for same.

NOTE

Failure to comply with cost and reserve reporting requirements set forth in LAC 37:III, §§1101-1105 could result in termination of PCF coverage.

Please mail or fax to:

LOUISIANA PATIENT'S COMPENSATION FUND
P.O. BOX 3718
BATON ROUGE, LA 70821

FAX: (225) 342-5593

Signature of Insured -- NOT VALID WITHOUT SIGNATURE

Date

A PRINTED, SIGNED COPY OF THIS FORM MUST BE MAILED/FAXED TO PCF.

PCF coverage is subject to all agreements, conditions and exclusions of the underlying policy unless such agreements, conditions and exclusions are expressly prohibited by law.

Additional forms may be found on the LAPCF website: www.lapcf.info

Any questions regarding this form may be emailed to: pcf-surcharge@la.gov