Private Practice Section - APTA

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S.C. WWW 1BE SURE TO COMPLETE ALL PAGES AND SIGN LAST PAGEHCPAPP-1000 (Ed.04/2010)

APTA

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PROFESSIONAL LIABILITY INSURANCE APPLICATIONUnderwritten by Liberty Insurance Underwriters Inc.

HOW TO APPLY:1. Complete application below.2. Note the premium below for the policy you selected.All premiums are annual.3. Return your completed application, along with your annualpremium, to the address provided.All coverages elected must be under the same policy limits.Coverage is effective the date your application is approved andpayment is received. Please allow three to four weeks fordelivery of your certificate. Please print or type allinformation.Visit www.proliability.com for more information and to viewavailable professions for applying online.

RESIDENTS OF LOUISIANA ONLY1. APPLICANT INFORMATION (All applicants must complete. Please print all information.)

__________________________________________________________________________________________________________________________________________INDIVIDUAL APPLICANTS: FIRST NAME INITIAL LAST NAME

__________________________________________________________________________________________________________________________________________BUSINESS APPLICANTS: CORPORATE NAME / DBA / YOUR NAME, IF NOT INCORPORATED (COMPLETE ONLY IF YOU OWN THE BUSINESS)

__________________________________________________________________________________________________________________________________________BUSINESS APPLICANTS: NAMES OF OWNERS, PARTNERS AND CORPORATE OFFICERS WHO ARE ACTIVE IN THE BUSINESS AND THEIR PROFESSIONALOCCUPATION

__________________________________________________________________________________________________________________________________________PHYSICAL STREET ADDRESS (MUST COMPLETE) CITY STATE ZIP

__________________________________________________________________________________________________________________________________________MAILING ADDRESS (IF DIFFERENT THAN ABOVE) CITY STATE ZIP

__________________________________________________________________________________________________________________________________________BUSINESS PHONE# FAX # HOME PHONE #

__________________________________________________________________________________________________________________________________________E-MAIL ADDRESS

__________________________________________________________________________________________________________________________________________WEBSITE ADDRESS

2. DEFINITIONSEmployed means you receive a W-2 and are not an owner of the legal entity that issues your W-2. Individual Employedcoverage is not available if you have employees or independent contractors working on your behalf.Self-Employed is a professional who functions full or part-time as an independent agent with private patients, or as theowner of a business, paid on a fee-for-service basis.

3. EMPLOYED INDIVIDUALSANNUAL LIMITS AND PREMIUMS$2,000,000 per incident/occurrence $1,000,000 per incident/occurrence$4,000,000 annual aggregate $3,000,000 annual aggregate

Professional Designationq Employed Physical Therapist q $213 q $182

q Employed Physical Therapist Assistant q $94 q $80

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4. UNDERWRITING DATA - EMPLOYED INDIVIDUAL APPLICANTS ONLY (Required for employedapplicants - please answer all questions to prevent underwriting delays.) (Attach an explanation for all “ YES”responses on a separate sheet of letterhead.)

1. Have you or any of your employees ever had the following: revoked, suspended, refused, denied renewal, placed onprobation, cancelled, or voluntarily surrendered by you or any of your employees or is such an action pending? (If Yes,explain on a separate sheet of paper, please include dates and details.)

State License or Certification q YES q NO

Malpractice Insurance q YES q NO

2. Has any claim or suit ever been brought against you or any of your employees or are you or any of your employeesaware of any incident that might reasonably lead to a claim or suit? (If Yes, explain on a separate sheet of paper, pleaseinclude dates, allegations and amounts.) q YES q NO

EMPLOYED INDIVIDUALS PROCEED TO DECLARATION AND SIGNATURE.

5. SELF-EMPLOYED INDIVIDUALS & BUSINESS APPLICANTSANNUAL LIMITS AND PREMIUMS$2,000,000 per incident/occurrence $1,000,000 per incident/occurrence$4,000,000 annual aggregate $3,000,000 annual aggregate

Professional Designation

A. A premium must be paid for all owners, partners and principals active in the business.

q Self-Employed Physical Therapist ( ) x $674 = $______ ( ) x $576 = $______

q Self-Employed Physical Therapy Assistant/Aide ( ) x $316 = $______ ( ) x $270 = $______

q Other (Owner who is not one of the above professions) ( ) x $___ = $______ ( ) x $___ = $______

______________________________________________________(Please specify occupation and contact administrator for premium)

B. A premium must be paid for each employee.q Physical Therapist(s) ( ) x $439 = $______ ( ) x $375 = $______

q Athletic Trainer(s) ( ) x $439 = $______ ( ) x $375 = $______

q Massage Therapist(s) ( ) x $439 = $______ ( ) x $375 = $______

q Occupational Therapist(s) (OTR & COTA) ( ) x $439 = $______ ( ) x $375 = $______

q Physical Therapy Assistants/Aides ( ) x $439 = $______ ( ) x $375 = $______

q Nurse(s) (Excluding NP & CNS w/PDA) ( ) x $439 = $______ ( ) x $375 = $______

q Speech/Hearing Therapist(s) ( ) x $439 = $______ ( ) x $375 = $______

q Other Employee: ( ) x $439 = $______ ( ) x $375 = $______

______________________________________________________(Please specify occupation)

C. A premium must be paid for each independent contractor.q Independent Contractors ( ) x $59 = $______ ( ) x $50 = $______

NOTE: This policy covers vicarious liability claims made against you or your business as a result of professional servicesrendered by an Independent Contractor working under your direction. To reduce your exposure, you should annuallyrequire and verify that all Independent Contractors purchase and maintain their own professional liability policy. Beadvised that your policy will not directly or indirectly defend any Independent Contractor(s).

The number of contractors used above in determining premium must equal the number answered in Section 11,Question 12 (c).

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HCPAPP-1000 (Ed.04/2010)

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6. OPTIONAL COVERAGES (SELF-EMPLOYED INDIVIDUALS AND BUSINESS APPLICANTS ONLY)ANNUAL LIMITS AND PREMIUMS$2,000,000 per incident/occurrence $1,000,000 per incident/occurrence$4,000,000 annual aggregate $3,000,000 annual aggregate

General Liability

*Please attach name and physical address for each location.(Property owned or rented by the named insured)1st location q $140 q $120

Additional location(s) ( ) x $59 = $______ ( ) x $50 = $______

Additional Insured

*Please attach name and physical address for each facility.(This coverage is for facilities that you maintain contracts with which REQUIRE you to add them as an additional insuredon your insurance certificate.)Professional Liability Only ( ) x $146 = $______ ( ) x $125 = $______

General Liability Only (available only if General Liability is

purchased above) ( ) x $30 = $______ ( ) x $25 = $______

Professional & General Liability (available only if General

Liability is purchased above) ( ) x $176 = $______ ( ) x $150 = $______

*To prevent underwriting delays, please submit this information if coverage is required.

7. SUBTOTAL SECTIONS 5 & 6$_______________ $_______________

8. IF YOUR PRACTICE CONSISTS OF:A. TWO OR MORE PROFESSIONALS,

Total of premium entered in Section 7 above X .15 = $_______________ $_______________

B. PROVIDE 40% OR MORE OF TREATMENT OR ASSESSMENT TO WORKERS COMPENSATION PATIENTS,Total premium entered in Section 7 above X .20 = $_______________ $_______________

9. CALCULATE YOUR PREMIUMTOTAL LIABILITY PREMIUM (Add Sections 7 & 8, ROUND TO THE NEAREST WHOLE DOLLAR) $

Your individual practice risk characteristics may warrant use of a premium modification factor based upon companyunderwriting discretion.

10. SEPARATE ENTITY LIMITS OF LIABILITY (Optional coverage for Business Applicants Only)A separate Limit of Liability for a legal entity may be available for an additional premium. Be advised that a request for aseparate Limit of Liability for an entity requires a referral to the carrier and may delay a final decision on your application,our ability to offer a firm quote, and bind coverage. The separate Limits of Liability for the entity are only available at the$1,000,000 per incident/occurrence and $3,000,000 annual aggregate level.Please check the box below if you would like to apply for separate Entity Limits of Liability.q Separate Entity Limits of Liability (Minimum Additional Premium is 17% or more of Total Premium Due, Section 9)

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11. SELF-EMPLOYED INDIVIDUALS & BUSINESS APPLICANTS ONLY MUST ANSWER(Required - please answer all questions to prevent underwriting delays.) All Self-Employed must completequestions 1-12. (Attach an explanation for all “YES” responses on a separate sheet of letterhead.)

1. Have you or any of your employees ever had any of the following: revoked, suspended, refused, denied renewal,placed on probation, cancelled, or voluntarily surrendered or is such an action pending?

State License or Certification q YES q NO

Malpractice Insurance q YES q NO

2. Has any claim or suit ever been brought against you or any of your employees or are you or any of your employeesaware of any incident that might reasonably lead to a claim or suit? q YES q NO

3. Indicate type of Business: q Corporation q Partnership q Sole Proprietor q Other

4. Please describe the services you, your corporation and its employees provide:

5. Please provide a brochure and/or web address that you use in the course of your business.

6. Do you own or operate any of the following?

a. Overnight bed facilities or provide any overnight care? ...................................................................q YES q NO

b. Staffing Agency? ........................................................................................................................q YES q NO

c. Health Club/Fitness/Exercise and/or Wellness Center of Sports Endurance or Enhancement Facility? .q YES q NO

d. A business other than Physical Therapy?.......................................................................................q YES q NO

If yes, please explain:

7. Do you or any of your employees offer weight control or diet programs?...............................................q YES q NO

8. Do you or any of your employees provide treatment or assessment in a nursing home and/or assistedliving facility? .................................................................................................................................q YES q NO

If yes, please explain your activities and include the total percentage of your time that you providetreatment in these facilities:

9. Do you or any of your employees administer anesthetics or radiation therapy? ......................................q YES q NO

10. Are all professionals listed on the application certified and/or licensed for the duties they areperforming? ...................................................................................................................................q YES q NO

If no, please explain:

11. Do you engage in any business enterprise other than physical therapy and/or medical rehabilitation? ....q YES q NO

If yes, please explain:

12. Do you or your business (if any) use independent contractors? (If YES, answer questions a-f.) ..............q YES q NO

a) How many independent contractors have you used in the past 12 months?b) How many total full or partial days did you use independent contractors in the last 12 months?c) How many independent contractors do you intend to use over the next 12 months?

A premium must be paid for every independent contractor identified on question 12c.d) Do you require in writing that all independent contractors carry their own professional liability? ...........q YES q NO

e) Do you request to be added as an Additional Insured on all independent contractor’s policies?............q YES q NO

f) Do you always secure written proof of professional liability from all independent contractors? ..............q YES q NO

I understand that I am not covered by this insurance for rendering or failure to render any professional services as aphysician, surgeon, dentist, nurse midwife, nurse anesthetist, perfusionist, cytotechnologist, chiropractor, podiatrist,osteopath, or psychiatrist. I understand that these professional occupations are excluded from coverage. I understandthat this insurance will not apply to any partner, principal or owner of a residential/overnight facility. The insurancedescribed herein is subject to the terms, conditions and exclusions of the insurance policy. The insurance is excess whenother insurance applies to a loss.

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HCPAPP-1000 (Ed.04/2010)

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In order to enhance the stability of this professional liability insurance program, coverage has been organized through apurchasing group, pursuant to legislation, known as the Federal Liability Risk Retention Act of 1986, enacted byCongress. Coverage is provided to the purchasing group by Liberty Insurance Underwriters Inc. Once the completedapplication has been approved and the premium has been received, you will automatically become a member of theHealth Care Professions Purchasing Group Association, located and domiciled in Illinois and obtain the insurancecoverage afforded through the Group Policy on an annual term.This application is subject to the underwriter’s approval. Your completion of this application and premium payment doesnot bind coverage or obligate the insurance company to issue you insurance coverage. Coverage will become effectivefollowing the receipt of your acceptable application and premium payment. Your application cannot be processed unlessit is completed in its entirety. The application is subject to the company’s underwriting rules.

Illinois Only - Illinois Medical Professional Liability Law PA94-677

Illinois Medical Professional Liability Law PA94-677, Senate Bill 475, requires insurers to implement a quarterly premiumpayment installment plan as prescribed by the Secretary of the Illinois Department of Financial and ProfessionalRegulation (IDFPR).If you practice in the state of Illinois and your annual medical professional liability premium is above $500, please visitwww.proliability.com/illinstall for information regarding installment payment options.

YOU MUST SIGN AND DATE THIS APPLICATION

(ALL STATES EXCEPT AR, CO, DC, FL, HI, KY, LA, ME, MD, NJ, NM, NY, OH, OK, PA, TN, VA, WA, WV): ANYPERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY lNSURANCE COMPANY OR OTHERPERSON, FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANYMATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATIONCONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS ACRIME.ARKANSAS, LOUISIANA, AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS AFALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSEINFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINESAND CONFINEMENT IN PRISON.COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADINGFACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING ORATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OFINSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANYWHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO APOLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THEPOLICY HOLDER OR CLAIMING WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FOR INSURANCEPROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENTOF REGULATORY AGENCIES.DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADINGINFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OF ANY OTHER PERSON.PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCEBENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD ORDECEIVE ANY INSURANCE COMPANY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE,INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.HAWAII APPLICANTS: FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THATPRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS A CRIME PUNISHABLE BYFINES OR IMPRISONMENT, OR BOTH.KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCECOMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLYFALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONTAINING ANYFACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.MAINE, TENNESSEE, VIRGINIA, AND WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDEFALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OFDEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OFINSURANCE BENEFITS.

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MARYLAND APPLICANTS : ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE ORFRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLYPRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BESUBJECT TO FINES AND CONFINEMENT IN PRISON.NEW JERSEY APPLICANTS : ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON ANAPPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.NEW MEXICO APPLICANTS : ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIMFOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN ANAPPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAYBE SUBJECT TO CIVIL FINES AND CRIMINALPENALTIES.NEW YORK APPLICANTS : ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCECOMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIMCONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING,INFORMATION CONCERNING ANY MATERIAL FACT THERETO, COMMITS A FRAUDULENT INSURANCE ACT,WHICH IS A CRIME, AND SHALL BE ALSO SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSANDDOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.OHIO APPLICANTS : ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATINGA FRAUD AGAINST AN INSURER SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE ORDECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.OKLAHOMA APPLICANTS : WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE,DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICYCONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY.PENNSYLVANIA APPLICANTS : ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANYINSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OFCLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OFMISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENTINSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.Declaration and Signature -The undersigned, on behalf of all prospective insureds, after a reasonable inquiry, declares to the best of his/herknowledge and belief that the statements contained herein are true and are the basis of the acceptance of the risk or thehazard assumed by the Company under this Policy. It is further agreed by the undersigned, its Subsidiaries and theirdirectors, officers and trustees that the Policy, if issued, is in reliance upon the truth of such representations. It is agreedthat, although the signing of the Application does not commit the undersigned to purchase the insurance being appliedfor, the statements made in this Application shall become the basis of the Policy should one be purchased. The Companyis hereby authorized to make any investigation and inquiry in connection with this Application deemed necessary._______________________________________________________ __________ _____ / _____ / ____Signature of Applicant or Authorized Partner / Officer / Owner Title Date_____________________________________________Name of individual signing this application (printed)

Enclosed is my check for $__________________ Effective Date Desired*_______________Make check payable to Mercer Consumer and return your check and this application in the envelope provided.*May not be earlier than the date the administrator receives and approves this application.

PLEASE NOTE: We do not accept American Express or Discover

Credit Card Number: ____________________________________________________________________

Expiration Date: ________________________________________________________________________

Print name exactly as it appears on card: ____________________________________________________If paying by credit card, you may fax your application to 515-365-6338.

I authorize Mercer Consumer to charge my: ❑ VISA ❑ MasterCard Amount $_______________

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HCPAPP-1000 (Ed.04/2010)

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Administrator:

Mercer Consumer ProliabilityP.O. Box 310395Des Moines, IA 50331-03951-800-503-9230www.proliability.com

Underwritten by: PLE-PTLiberty Insurance Underwriters Inc.

CA License #0G39709Mark Brostowitz, Licensed AgentIn CA d/b/a Mercer Health & Benefits Services LLC

Copyright 2014 Mercer LLC. All rights reserved.

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LIBERTY INSURANCE UNDERWRITERS INC.(A member of Liberty Mutual Group and hereinafter “the Company”)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

POLICYHOLDER DISCLOSURE – TERRORISM INSURANCE PREMIUM NOTICE

This notice contains important information about the Terrorism Risk Insurance Act and its effect onyour policy. Please read it carefully.

THE TERRORISM RISK INSURANCE ACT

The Terrorism Risk Insurance Act, including all amendments (“TRIA” or the “Act”), establishes a program to spread therisk of catastrophic losses from certain acts of terrorism between insurers and the federal government. If an individualinsurer’s losses from a “certified act of terrorism” exceed a specified deductible amount, the government will reimbursethe insurer for 85% of losses paid in excess of the deductible, but only if aggregate industry losses from such an actexceed $100 million. An insurer that has met its insurer deductible is not liable for any portion of losses in excess of $100billion per year. Similarly, the federal government is not liable for any losses covered by the Act that exceed thisamount. If aggregate insured losses exceed $100 billion, losses up to that amount may be pro-rated, as determined bythe Secretary of the Treasury.

MANDATORY OFFER OF COVERAGE FOR “ CERTIFIED ACTS OF TERRORISM” AND DISCLOSURE OFPREMIUM

TRIA requires insurers to make coverage available for any loss that occurs within the United States (or outside of theU.S. in the case of U.S. missions and certain air carriers and vessels), results from a “certified act of terrorism” AND thatis otherwise covered under your policy.

A “certified act of terrorism” means:

[A]ny act that is certified by the Secretary [of the Treasury], in concurrence with the Secretary of State, and theAttorney General of the United States

(i) to be an act of terrorism;

(ii) to be a violent act or an act that is dangerous to –

(I) human life;

(II) property; or

(III) infrastructure;

(iii) to have resulted in damage within the United States, or outside of the United States in the case of

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TRIA-N001-0208

Effective Date:

Policy Number:

Issued To:

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(I) an air carrier (as defined in section 40102 of title 49, United States Code) or United States flag vessel (or avessel based principally in the United States, on which United States income tax is paid and whoseinsurance coverage is subject to regulation in the United States); or

(II) the premises of a United States mission; and

(iv) to have been committed by an individual or individuals as part of an effort to coerce the civilian population ofthe United States or to influence the policy or affect the conduct of the United States Government by coercion.

MANDATORY PREMIUM DISCLOSURE STATEMENT

Your policy does not contain an exclusion for losses resulting from “certified acts of terrorism.” Coverage for suchlosses is still subject to, and may be limited by, all other terms, conditions and exclusions in your policy.

The premium charge for this coverage for the policy period is $0.

YOU NEED NOT DO ANYTHING FURTHER AT THIS TIME.

The summary of the Act and the coverage under your policy contained in this notice is necessarily general in nature.Your policy contains specific terms, definitions, exclusions and conditions. In case of any conflict, your policy languagewill control the resolution of all coverage questions. Please read your policy.

If you have any questions regarding this notice please contact your sales representative or agent.

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TRIA-N001-0208

In this transaction, Mercer Consumer, a service of Mercer Health & Benefits Administration LLC, is acting asthe exclusive insurance agent and program manager for Liberty Insurance Underwriters Inc. (Insurer) for this type of coverage, and not as your insurance broker. As the agent for Insurer, Mercer Consumer mayprovide these services: enrollments, ongoing servicing, billing, marketing, customer administrative and claimservicing and communications. In accordance with industry custom, we are compensated through commissions that are calculated as apercentage of the insurance premiums charged by insurers. We may also receive additional monetary andnonmonetary compensation from insurers or from other insurance intermediaries, which may be contingentupon such factors as volume, growth or retention of business. This compensation may include paymentfrom insurers for marketing-related expenses or investments in technology. Our compensation may varydepending on the type of insurance purchased and the insurer selected. We will provide you additionalinformation about our compensation upon your request.

You may obtain this information by referring to https://www.personal-plans.com/disclosure and entering the security code o3975329 or call us at 1-888-206-5088 for specific details.

Mercer Consumer Insurance Compensation & Disclosure

To review the applicable Liberty policy form, you may download it at our website:https://www.proliability.com/lp/plpolicyforms/index.html. Once you have been approved for coverage, you willalso receive a complete packet of your policy documents.

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Professional Liability Insurance ProgramMore Opportunities, MoreResponsibilities, More Risk

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The most responsible, skilled and experienced PT’s caninnocently become involved in malpractice claims. Aspatients are released for physical therapy sooner than everbefore, your exposure to risk is growing all the time.Consider these real-life incidents:Allegation: Fall off therapeutic ball caused injury.Detail: PT attempted to place an ankle weight on thepatient while the patient was sitting on a therapeutic ball.The patient fell off the ball, breaking an arm and sufferinghead injuries.Outcome: The claim was settled against the PT in theamount of $72,379.Allegation: Numbness during leg traction.Detail: The patient was being treated post-surgicallyfollowing a fusion at C5-C7. During regularly scheduledtreatment, the patient complained to the PT of lower backpain.While the patient was lying on his back with his legs inslight abduction, the PT applied mild traction whileinstructing the patient to take a few deep breaths. Thepatient coughed and then noted increased numbness in hisleg (PT’s version).The patient stated that the PT pulled on the leg with atwisting motion causing immediate and severe pain.An MRI showed a herniated disc at L5-S1. The treatingphysician was angry with the PT for treating the lumbararea, which was not prescribed.Outcome: The claim was settled against the PT for$41,000.

Employer Provided Coverage is LimitedYou can’t rely solely on the liability protection provided byyour employer. Without your own professional liabilityprotection, you could end up paying all attorney fees, courtcosts and loss of wages out of your own pocket because . . .

l There may be gaps in your employer’s policy.l A suit may be filed after you have terminated

employment.l Most employer-provided coverage does not cover you

for actions that take place outside the workplace or foractions performed outside of your job description orwhen established procedure was not followed.

l With employer-provided coverage, you have to shareyour coverage with your co-workers, your employer andthe business entity.

l A consolidated defense for an employer usuallyrepresents the interest of the employer, not you.

This protection is yours alone—it is not shared with yourco-workers and your institution. The plan includes aqualified “consent to settle” clause which requires yourconsent to settle claims.And, it protects you if someone you supervise, and forwhom you are legally liable, is named in a suit.

Coverage FeaturesYour Choice of Professional Liability Coverage Limits$1,000,000 or $2,000,000 per incident, $3,000,000 or$4,000,000 annual aggregate. Provides protection whetheryou are employed full-time or part-time.

Supplemental Liability Coverage Limits(Individuals only)$1,000,000 or $2,000,000 per occurrence, $3,000,000 or$4,000,000 annual aggregate. Covers you for bodily injury,property damage and personal injury occurrences notrelated to your professional duties.

Defense CostsLegal fees and court costs incurred by the insurer on yourbehalf will be paid for covered claims, in addition to theliability limits, even if the suit is groundless, false orfraudulent, up to the limit of liability of the policy.

Licensing Board HearingsUp to $5,000 per hearing/$10,000 annual aggregate for theinvestigation or defense of covered proceedings beforemost entities responsible for regulating your professionalconduct (i.e. licensing board).

Loss of EarningsYou will receive payment for loss of earnings for yourattendance at a trial, hearing or arbitration proceeding atthe Company’s request, subject to a maximum limit of$10,000 per incident. “Reasonable expenses” are included.

Deposition ReimbursementThe coverage provides you with expense reimbursement,up to $5,000, for legal representation for depositions relatedto your professional duties. This coverage applies when youare not named in a suit but are required to be deposed, i.e.,as a witness to the event. This coverage does not apply toany services you provide as an “expert witness.”

Locum TenensThe policy provides coverage when another professionaltemporarily assumes your duties and provides services onyour behalf for a specific period of time. The locum tenensshares in your limits of coverage.(Available to self-employed individuals and groups.)

Managed Care ContractsIf you assume liability in a managed care contract, you willbe covered for negligent acts, for which you are solelyresponsible.

Claims SettlementThe policy contains the important qualified “consent tosettle” clause which requires your consent to settle claims.Subject to federal and state regulations and laws.

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Damage to Property of Others Coverage(Individuals only)You will receive up to $500 per policy period for damageyou unintentionally inflict on the property of others duringany non-business pursuit, yet related to your professionalduties.

Medical Payments Coverage(Individuals only)You will receive medical payments coverage fornon-business pursuits if someone is injured in or aroundyour home—up to $1,500 per person/ $75,000 for allpersons. Your policy pays medical expenses incurred up to4 years after the injury occurs.

Worldwide ProtectionYou are covered anywhere in the world, as long as theclaim is made or suit is brought in the U.S., its territories orpossessions or Canada.

First Aid ReimbursementThe policy will reimburse you up to a maximum of $2,500for all medical supplies you purchase and use in order torender first aid to another as covered by the certificate.

Assault CoverageThe policy pays up to $5,000 per assault/ $10,000 annualaggregate for medical expenses resulting from bodily injuryto you or damage to your personal property if you areassaulted at work. You are also covered when traveling toand from the workplace.

Self-employed Individuals & Group Practices“Products Hazard” Coverage for equipment specificallydesigned, made or altered by you for a patient or client.

Separate Annual aggregatesEach professional member of an insured group will have aseparate annual aggregate limit.

Coverage for Volunteers and Employees.

Optional Coverages:

General Liability CoverageIncludes bodily injury and property damage associated withyour business, but not your professional services, personalinjury and advertising injury liability for your own businessor practice and fire legal liability.

Additional Insured CoverageProtects a healthcare facility you provide services toagainst claims arising out of the sole negligence of thepersons insured. You should only purchase this if thefacility requires you to.

Entity CoverageSeparate limits of coverage equal to those selected for theprofessional members are available for the entity, up to$1,000,000/ $3,000,000, for an additional premium. Thisfeature provides the entity with a separate set of limits.

Protection You Can Count On, Now and in the FutureBecause our program uses an “occurrence form,” you arecovered for professional services performed during theterm of the insurance certificate . . . no matter when the suitor claim is made. So, you have this protection now and inthe future for any claims resulting from covered servicesyou performed while the insurance certificate was in force.

The CompanyMercer Consumer has been a leader in providinginsurance protection to health care professionals since1949. The Mercer Consumer Professional LiabilityInsurance Program is endorsed by over 200 professionalstate and national organizations.Mercer Consumer and the Liberty InsuranceUnderwriters Inc. have worked closely together to developone of the most competitive programs available forPhysical Therapists. As the administrator of this program,Mercer Consumer is dedicated to providing you withthe customer service you deserve.

Administered by:

Mercer Consumer ProliabilityP.O. Box 310395Des Moines, IA 50331-03951-800-503-9230www.proliability.com

Underwritten by:Liberty Insurance Underwriters Inc.This brochure contains a summary of the insurancecertificate provisions. If there is a conflict between thisbrochure and the actual insurance certificate, the insurancecertificate language will control.

RestrictionsThis program is designed to provide professional liabilityinsurance protection. You are not covered while operating amotor-driven vehicle, when engaged in any other businessoutside your professional duties, when engaged in anunlawful action, or when acting as a proprietor, owner,partner, manager, superintendent, or officer of any hospital,sanitarium, medical clinic, health maintenanceorganization, managed care facility, foster care agency,adoption agency or any other facility not specified in theDeclarations. You are not covered when acting as aphysician, surgeon, dentist, nurse midwife, chiropractor,podiatrist, osteopath, psychiatrist, cytotechnologist, orperfusionist or any other medical specialist not named inthe Declarations. See insurance certificate for complete listof exclusions.

Copyright 2014 Mercer LLC. All rights reserved. PLP-PT

CA License #0G39709Mark Brostowitz, Licensed AgentIn CA d/b/a Mercer Health & Benefits Insurance Services LLC