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State of West Virginia Recredentialing Form:  Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment.  (If more space is needed, please supply the information on a separate sheet and attach.)

15.Professional Liability Insurance Coverage Disclosure:  (Respond only for actions since date of last credentialing.)

If the answer to any of these questions is Yes, please provide a full explanation of the details of each and every matter on the attached Professional Liability Information Addendum.  The explanation must include the name of the court in which the suit was filed, the caption and docket number of the case, and the name and address of the attorney defending you, and all other relevant details.  Include suits in which a judgment or settlement was made against a professional corporation of which you are/were a member, shareholder, or employee in any matter in which you were involved in the patient’s care.

A.Has your professional liability insurance coverage ever been terminated by action of the insurance company?

No

Yes

B.Have you ever been denied professional liability insurance coverage?

No

Yes

C.Has any (current or previous) professional liability insurance carrier excluded any specific procedures or specific area of practice (e.g., obstetrics, surgery, etc.) from your coverage?

No

Yes

D.During the time of your professional practice, have you had any professional liability claims, suits, settlements, or judgments filed against you or are any currently pending?

No

Yes

E.Have any restrictions ever been placed on your professional liability insurance coverage?

No

Yes

F.Have you ever practiced without professional liability coverage?

No

Yes

G.Are there any incidents for which you have been contacted by an attorney regarding potential professional liability (e.g., settlement requests, writ of summons, etc.)?

No

Yes

12/02; 3/03; 11/03; 1/04; 5/04; 10/04     **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 15

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