Professional Liability Application

Physicians Insurance

Volunteer and Retired Providers (VRP) Program Claims-Made Professional Liability Application


Thank you for your interest in the the Volunteer and Retired Providers (VRP) Program! To learn more about the VRP Program, please click here


The following electronic application (press "Next" below) is for VRP malpractice insurance. 


If you believe that you have already applied for VRP malpractice insurance, or if you have any questions, please contact Kris Ives at: 


267-713-9422 


If you prefer to submit a paper form, you can click on this link to download the form (out of state providers click here).

APPLICANT DEMOGRAPHICS






























VOLUNTEERING INFORMATION


When do you begin volunteering?
Please let us know an approximate start date for your volunteer work in order to assign a date for your malpractice insurance.

Where will you be volunteering?
The VRP Program covers providers who are volunteering at program-approved sites across Washington. Please "check" all sites where you will be volunteering.

You can hold down the keys "CONTROL+F" on a PC or "COMMAND+F" on a Mac to find your site in the below list.

If you cannot find your volunteer site in the list below, please select "other" at the bottom and type where you'll be volunteering.



PROFILE QUESTIONS









VRP AUTHORIZATION




Scope of Care & Authorization

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Scope of Care

The VRP Program only covers non-invasive care. Please acknowledge that you understand the scope of care covered through the VRP Program.

I understand that I will only perform non-invasive care as defined below:

Non-invasive care includes the administration of injections, suturing of minor lacerations, and the incision of boils and superficial abscesses. Obstetric care and procedures coded as surgery are not covered under noninvasive medical care. Non-invasive dental care includes diagnosis, oral hygiene, restoration, and extraction. Orthodontia and surgical treatments are not covered by VRP malpractice insurance.

Authorization

I acknowledge that as a condition precedent to acceptance of this application and any future renewal thereof, an inquiry and investigation of my professional background, qualifications and competence, including such other underwriting or claim matters as are deemed relevant, may be conducted by Physicians Insurance or its duly authorized representatives. I expressly consent to any such inquiry and investigation and hereby authorize the release and exchange of information pertaining to such inquiry and investigation between any professional organizations in which I am or have been a member, their insurance consultants or agents, any hospitals at which I hold or have ever held staff privileges or have had an application for staff privileges denied, any state licensing agency, any of my attending or treating physicians, the Washington Physicians Health Program, any prior insurance carriers, prior employers or professional associates and Physicians Insurance or its duly authorized representatives. I hereby release and discharge the providers of information, Physicians Insurance, its duly authorized representatives and the members or consultants of any established peer review committees from any and all legal liabilities which might otherwise be incurred as a result of any communications, reports, disclosures and recommendations made or any acts performed, in good faith, in connection with any inquiry or investigation initiated by Physicians Insurance or its duly authorized representatives. I agree to notify Physicians Insurance immediately, in writing, if there are any changes from which I have described in this application, including changes in my practice, in my partners or associates, medical license, professional office premises, practice locations, medical procedures or administrative responsibilities and hospital privileges. I understand that Physicians Insurance does not cover any liability of another person or organization with whom I assume an oral or written contract or agreement.

Washington State law requires us to inform you of the following: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.