Skip to content
Kansas Health Care Stabilization Fund Compliance Form
Step
1
of
5
20%
Section A - Health Care Provider Identification and Residency Status
1. Kansas License Number
*
2. Provider Type
*
Individual
Business
2a. Profession
Please select a profession
CNM
CRNA
DC
DDS
DO
DPM
MD
PhyA
2b. Facility Type
Please select a Facility Type
Hospital
ASC
CMHC
PA
LLC
Partnership
Charter
ALF
NF
RHCF
3. Last Name OR Business Name
*
Enter the Health care providers last name or the complete name of medical facility or business entity name.
4. Professionals First Name
5. Middle Name or Initial
6. Suffix
7. Telephone Number
*
8. Email Address
9. Legal Residence
Legal residence address of health care professional or street address location of medical care facility or business: NOTE: For health care professionals, this must be the home address (legal domicile).
9a. Street Address
*
9b. Residence City
*
9c. State
*
Please select
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DIST OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
Non-USA
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
9d. ZIP
9e. ZIP Ext.
10. Business Mailing Address
10a. Name of group practice, medical clinic, or other business
10b. Street Address or PO Box
10c. City
10d. State
Please select
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DIST OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
Non-USA
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
10e. ZIP
10f. ZIP Ext.
Section B - Commercial Insurance Information
NOTE: A certificate of insurance is required for all non-resident health care providers. The information on this compliance form will not be accepted nor will the health care provider be in compliance with KSA 50-3401 et seq until the certificate of insurance and the appropriate HCSF premium surcharge have been received and accepted.
11a. Insurance Company Name
*
Please select Insurance Company
ACE AMERICAN INS CO
ADMIRAL INSURANCE COMPANY
ALLIED WORLD SURPLUS LINES CO(FKA DARWIN SELECT INS CO)
AMCO INS CO
AMERICAN CASUALTY CO. OF READING, PA
ARCH SPECIALTY INS CO
COLONY SPECIALTY INSURANCE COMPANY?NO LONGER WRITING 10-1-2016
CONTINENTAL CASUALTY CO
COPIC INS CO
COVERYS SPECIALTY INSURANCE COMPANY
DEPOSITORS INS CO
EMERGENCY PHYSICIANS INSURANCE EXCHANGE, RRG
EVANSTON INS CO
GUIDEONE AMERICA INSURANCE COMPANY
GUIDEONE SPECIALTY MUTUAL INSURANCE COMPANY
HEALTH CARE INDEMNITY, INC.
HEALTH CARE INDUSTRY LIABILITY RECIPROCAL INSURANCE CO., RRG
INTERMED INS CO
KAMMCO CASUALTY COMPANY, INC.
KANSAS MEDICAL MUTUAL INSURANCE COMPANY
KS HEALTH CARE PROVIDER INS AVAIL PLAN
LANDMARK AMERICAN INS CO
LEXINGTON INS CO
LONE STAR ALLIANCE, INC, A RRG
MEDICAL LIABILITY ALLIANCE
MEDICAL PROTECTIVE CO (THE)
MEDICUS INSURANCE COMPANY
MISSOURI PROFESSIONALS MUTUAL INS CO
MMIC INSURANCE, INC.
NATIONAL FIRE & MARINE INS CO.
NATIONAL UNION FIRE INS CO OF PITTSBURGH PA
NATIONWIDE MUTUAL INS CO
NCMIC Insurance Company
OPHTHALMIC MUTUAL INS CO. (A RRG)
Other
PACO ASSURANCE CO INC
PEACE CHURCH RISK RETENTION GROUP (A RECIPROCAL)
PHYSICIANS LIABILITY INS CO
PODIATRY INS COMPANY OF AMERICA
PREFERRED PHYSICIANS MEDICAL RRG
PREFERRED PROFESSIONAL INS CO
PROASSURANCE CASUALTY COMPANY
PROASSURANCE INDEMNITY COMPANY, INC.
PROFESSIONAL SOLUTIONS INSURANCE COMPANY
SAINT LUKES HEALTH SYSTEM RRG
THE DOCTORS' CO, AN INTER-INS EXCH
ZURICH AMERICAN INS CO
11b. If field 11a = 'Other' then please enter Company Name
12a. Street Address or PO Box
*
12b. City
*
12c. State
*
Please select
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DIST OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
Non-USA
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
12d. ZIP
*
12e. ZIP Ext.
13a. Policy Number
*
14a. Effective Date
*
MM slash DD slash YYYY
14b. Expiration Date
*
MM slash DD slash YYYY
15. Type of Professional Liability
*
Please select type of liability. (C = Claims Made or O = Occurance)
C
O
16. HCSF Coverage limits per claim/annual aggregate
*
17. Annual Premium
*
18. Any unique features of this insurance policy?
Section C - Health Care Stabilization Fund Coverage
19. HCSF rate classification group number
*
20. For Kansas residents only - Active Missouri license (yes or no)
*
Please select yes or no.
No
Yes
21. HCSF coverage level: (5=$500k/$1.5 million)
*
Please select coverage level.
5
22. HCSF compliance year (1 - if greater than 1 years, please select 1)
*
Please select year of compliance.
1
23. Pro-rata year percent - please enter only the number without the % sign.
24. Annual HCSF Premium Surcharge
*
25. For non-residents only - ratio (percent) of practice allocated in Kansas
26. For both residents and non-residents - calculated HCSF Premium Surcharge (minimum=$200
*
Section D - Certification
For insurers of Kansas resident health care providers:
By selecting this box, I hereby certify that all the information provided via this document is correct and that the health care provider named in this document is aware of his or her coverage options pursuant to Kansas law and has deliberately selected the coverage level indicated on this form.
Name of insurance company representative
Rep Phone Number
Rep Email
For health care providers who are not legal residents of Kansas, but have an active license to practice in Kansas:
By selecting this box, I hereby certify that: (1) all information provided via this document is correct, (2) I have deliberately selected the HCSF coverage level, (3) the percentage indicated is a reliable estimate of the ratio of my Kansas practice compared to my entire practice, and (4) at this time I have no knowledge of any kind of professional liability claim or lawsuit attributable to my Kansas practice.
Attachment(s)
Upload supporting Documentation if applicable
Drop files here or
Select files
Accepted file types: pdf, Max. file size: 256 MB.
Method of Payment
*
Online Payment
Mail Check