Questionnaire for Those With
Limited or No Practice in Louisiana

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

Dear Provider:
If you are not engaged in patient care in Louisiana but still maintain your professional liability insurance, we would like to know the reasons for this so that we might serve you better. Below are some reasons why a provider might want to carry professional liability insurance in Louisiana even when not in active practice here. Please check all that apply to your situation. If you have other issues that are not addressed, please let us know. Also, please provide your profession and/or medical specialty.

Professional Specialty

Please indicate which of the following medical procedures you engage in:

I am in active practice in Texas, Arkansas, Mississippi or other nearby state and I sometimes care for patients from Louisiana.

I have withdrawn from active practice, but I sometimes provide gratuitous care for friends or family.

I have withdrawn from active practice, but I sometimes volunteer at emergency situations or during disasters.

I am in active practice for a private agency that provides professional liability coverage when I am on the job, but does not cover my actions outside the scope of employment.

I am in active practice for an agency that is covered by the Federal Tort Claims Act, the Louisiana State liability system, or the Louisiana Community Health Care Clinic limitations on liability, but does not cover my actions outside the scope of employment.

I am employed in research, teaching or administration where I do not provide or supervise patient care, but I am involved in records review, utilization review or other administrative duties involving individual patients or medical decisions.

Other:

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