LOUISIANA PATIENT’S COMPENSATION FUND
INSTITUTIONAL HEALTH CARE PROVIDERS’ APPLICATION
(for those with underlying self-insurance)

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

NAME AND PHYSICAL ADDRESS OF INSTITUTION

INSTITUTION NAME

License #

Institution Address Line 1 (no P.O. Box)

Address Line 2

Institution City, State Zip Code

Dates of Enrollment Applying for:

AMOUNT OF SURCHARGE BEING REMITTED:

IS THERE A SEPERATE OWNER? No Yes

IF SO, PLEASE PROVIDE THE NAME AND ADDRESS IF DIFFERENT FROM ABOVE HEALTHCARE PROVIDER?

OPERATIONS OF APPLICANT (Check ALL That Apply):

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.

PROFESSIONAL LIABILITY

PROFESSIONAL LIABILITY EXPOSURES (furnish daily census data):

Number of beds maintained: (Beds mean total number of beds, cribs and bassinets used for patients)		Average Number Occupied: (Average number occupied is the sum of the daily number of beds, cribs and bassinets used for patients during the preceding 12 months, divided by 365.)
	Acute
	Skilled/LATC
	Rehab
	Psych

ER Staffed By:

Number of outpatient visits: (Including outpatient and ambulatory surgeries.)
Number of inpatient surgeries:
Number of outpatient, ambulatory and "day"surgeries: (Included in "a" above.)

PROFESSIONAL EMPLOYEES

Please Indicate total number of employees in each class:

Registered Nurses

Heart-Lung Technicians

Pharmacists-(see rate manual)

Paramedics-(see rate manual)

X-Ray Technicians

EMTs-(see rate manual)

Lab Technicians

Other-EMT Intermediates

LPN/LVNs

Ambulance Service Student Learners

Are above employees to be included as additional insureds?	No	Yes
Employed physicians (including Medical Directors), surgeons, CRNAs, Surgical/Physician assistants, Nurse Practitioners and Pharmacists if paying for them separately must submit an individual application along with the appropriate surcharge.

PREVIOUS EXPERIENCE (NEW ENROLLEES ONLY)

Name of previous liability carrier:

List all claims or suits filed in the last ten years. Attach a separate list if necessary

DATE	DESCRIPTION	OPEN	CLOSED	TOTAL INCURRED

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.

I further certify that the appropriate security (proof of financial responsibility) is in place and current at the following institution:

	in the name of

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.

Please mail or fax to:

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

FAX: (225) 342-5593

Signature of ADMINISTRATOR -- NOT VALID WITHOUT SIGNATURE

Date

CONTACT PERSON AND PHONE NUMBER:

EMAIL ADDRESS:

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

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