Contact Information

Full Name(Required)

First Middle Last

Practice / Clinic Name

Primary Practice / Office Address(Required)

Street Address Apt, suite, bldg, floor, etc City State ZIP

Mailing Address

If same as above, check here

Mailing Address (Different from Practice Address)(Required)

Street Address Apt, suite, bldg, floor, etc City State ZIP

Email(Required)

Cell Phone(Required)

Office Phone

Cell Phone # and Office Phone # cannot be the same

Fax

Practice Background

1. Is your chiropractic license current?(Required)

Yes

Pending

If pending , please briefly describe why Pending.(Required)

Anticipated Licensure Date

Lic #

State

Issued Month

Issued Year

2. Do you use any technique not taught in the chiropractic schools and colleges?(Required)

Yes

If yes, please briefly describe the technique(s) and source of training.(Required)

3. Check if you treat any of the following and provide details

Cancer

Epilepsy

Diabetes

Peripheral Neuropathy

Provide more details if you treat any of the above(Required)

4. Check if you use any of the following and provide details

Colonics

Internal coccyx adjustment

Magnetic or gemstone therapy

Obstetrics

Prescription Drugs: Prescribing, dispensing, or administering

Stressology

Toftness Device

Provide more details if you use any of the above(Required)

5. If you intend to use any of the following, check any which are applicable (Any checked box may require a separate application and/or an additional premium to add the coverage, and is subject to underwriting approval.)

Acupuncture

Manipulation under anesthesia

Laser treatment

Breast Thermography

6. Do you make a differential diagnosis?(Required)

Yes

Do you limit your responsibility to identifying subluxations?(Required)

Yes

Provide an explanation if you do not limit your responsibility to identifying subluxations(Required)

7. When a patient needs treatment or diagnosis outside your scope of practice, do you refer them to other health providers?(Required)

Yes

If no, please explain how you manage patients whose condition falls outside chiropractic scope of practice.(Required)

8. If the quality of an x-ray film inhibits your ability to properly diagnose a patient's condition, will you always require a retake?(Required)

Yes

If no, please explain how you proceed when x-ray image quality is insufficient for accurate diagnosis.(Required)

9. Does anyone x-ray patients other than you, a qualified x-ray technician or licensed x-ray provider?(Required)

Yes

If yes, please provide the professional qualifications/licensure of the person(s) taking x-rays(Required)

10. Do you always require your patients to sign an informed consent prior to treatment?(Required)

Yes

Attach copy of form you use(Required)

Accepted file types: pdf, doc, docx, Max. file size: 5 MB.

11. Do you always record: the patient's account of their progress, objective findings, and details of treatment?(Required)

Yes

No, but I will now

If no, please briefly describe in what circumstance you would not record: the patient's account of their progress, objective findings, and details of treatment.(Required)

12. How many patients do you see per week?(Required)

How many hours per week do you spend professionally with patients?(Required)

What is the average time (minutes) you spend professionally with a patient on their first visit?(Required)

Only use minutes. Ex. 90 minutes =1 hour 30 minutes

Average length of time (minutes) spent for follow-up(Required)

Only use minutes. Ex. 90 minutes =1 hour 30 minutes

14. List any practice management company you have used

15. List any other professional healthcare license you hold (LAc, ND, RN, RPT, etc.)

16. Provide names and designations (ND, LAc, RN, PT, etc.) of other providers with whom you work or share space, etc.

17. Which best describes how you practice(Required)

Sole Proprietor

Professional Corp.

Partnership

Employee

Contractor

18. List any current chiropractic specialty designations / certifications held

19. List any chiropractic awards, teaching appointments, or published works

20. Do you currently hold hospital privileges or have completed a residency?(Required)

Yes

Hospital Name and Location(Required)

Date(Required)

Nature of Privileges / Reason for Termination(Required)

Add hospital 2

Add hospital

Hospital Name and Location(Required)

Date(Required)

Nature of Privileges / Reason for Termination(Required)

Add hospital 3

Add hospital

Hospital Name and Location(Required)

Date(Required)

Nature of Privileges / Reason for Termination(Required)

Add hospital 4

Add hospital

Hospital Name and Location(Required)

Date(Required)

Nature of Privileges / Reason for Termination(Required)

21. List pre-chiropractic college education

Claims and Other History

(If you answer Yes to any of the following, attach a detailed explanation including status, dates, and outcomes.)

1. Has any malpractice claim or allegation ever been asserted against you or your associates?(Required)

Yes

2. Are you aware of any event or indication suggesting a claim may be made against you or that your care might have been deficient or caused harm?(Required)

Yes

3. Has any agency or association ever investigated or taken any action against you or your license?(Required)

Yes

4. Have you ever had malpractice insurance denied, canceled, or accepted on special terms?(Required)

Yes

5. Have you been charged with or convicted of violating any law other than a minor traffic offense?(Required)

Yes

6. Have you ever provided services to clients when your ability to perform your professional duties was compromised because of a condition, or your use of an intoxicant, medication, or other drug?(Required)

Yes

Detailed explanation including status, dates, and outcomes(Required)

Drop files here or

Accepted file types: pdf, txt, doc, docx, Max. file size: 32 MB, Max. files: 6.

Please provide a detailed explanation for each of questions you answered YES in the section Claims and Other History above.

Coverage and Payment Options

1. How long have you been in Practice?(Required)

1st Year (0-12 Months)

2nd Year (13-24 Months)

3rd Year (25-36 Months)

More than 4 Years

2. Indicate below the Limit, Claims Reporting Basis, and Payment Plan applicable to you.

2.1. Coverage Limit(Required)

$1,000,000 / $3,000,000

$500,000 / $1,000,000

$200,000 / $600,000

2.2. Claims Reporting Basis(Required)

Occurrence

Claims Made (If you need a Retroactive Date, please call for a quote)

2.3. Payment Plan(Required)

Annual

10-Pay (Autopay required · finance fees apply)

3. Coverages Options

Additional Insureds (5% / Entity)

Business Personal Property (BPP) Coverage: $10,000 Limit, Lloyd’s of London: $105.72 / year

(Fully Paid at Enrollment)

To add an Additional Insured (Shared Limits) complete following. Indicate entity type.

My Professional Corporation

Other entity (Landlord, Mgmt. Co., etc.): 5% each

(If you need Separate Limits, please call for a quote.)

My Professional Corporation(Required)

Additional Insured Other Entity Name(Required)

2nd Additional Insured Other Entity Name

3rd Additional Insured Other Entity Name

This field is hidden when viewing the form

Share Limits 1

This field is hidden when viewing the form

Share Limits 2

This field is hidden when viewing the form

Share Limits 3

4. Who provides your current malpractice policy?

Expires

Amount Due

Annual Liability Coverage Amount Due(Required)

10-Pay Liability Coverage Amount Due(Required)

(For 10-Pay, just the first monthly installment is due on enrollment)

This field is hidden when viewing the form

Amount Due For Calc

Additional Insureds

Business Personal Property (BPP) Coverage

Total Current Amount Due

(If 10-Pay = 1st Month + Full amount of Coverage Options)

Select Payment Method

(Autopay is required for 10-Pay)

Payment Method(Required)

Credit Card

ACH Payment

Credit Card Type(Required)

Visa

MasterCard

American Express

ACH Payment(s) from(Required)

Personal Account

Business Account

Name on Card(Required)

Card #(Required)

Exp (MM/YYYY)(Required)

Account Name(Required)

Account #(Required)

Bank Name(Required)

Bank Routing #(Required)

Bank City(Required)

Declaration, Acknowledgement, Authorization & Signature

Declaration: I, the applicant, represent that:
1) I am applying for membership/coverage;
2) I signed/typed my name in the place(s) provided herein; and
3) The above statements are true, and I have not misstated or suppressed any facts.

I understand that:
1) If coverage is granted, my policy is issued in reliance upon such statements;
2) Such statements are deemed material;
3) Untrue statements could void my insurance;
4) This declaration, along with the information and disclosures contained herein, including any supplemental clarifications, are all a part of my application, shall be the basis of, and form a part of, my Policy, and shall apply to any subsequent renewal of that Policy;
5) There is no guarantee that coverage will be renewed; and
6) The Policy requires that I report, in writing, within 3 days, or as soon as practicable, incidents reasonably likely to involve this insurance, including oral or written patient complaints, threats, or lawsuits.

Claims Made Option: I understand that if I have selected the Claims Made option, my Policy will be limited to claims made against me during the Policy period arising out of the rendering of, or failure to render, professional services subsequent to the retroactive date. I understand that the Claims Made option provides that if the Policy terminates for any reason, there is no coverage for claims reported after the termination date (even though the injury occurred while the Policy was in force), unless I purchase Extended Coverage within 30 days after termination.

Authorization: If coverage is granted, I authorize you to:
1) Process payments when due, including any installments, by charging the Credit Card or debiting the Bank Account provided, in compliance with issuer agreements and U.S. law, and agree that this authority will remain in effect until I have canceled it in writing;
2) Request and receive information about me for any underwriting or claim-related inquiry from any professional association, licensing board or healthcare organization; and
3) Opt me in and allow the Company to communicate with me through Email, Fax, Phone, and SMS/ MMS messaging or other text messaging platforms.

NCC Elite Program requires the use of an NCC approved Arbitration Agreement and an Informed Consent as part of Patient intake.

Sign here(Required)

Please note: Signature must match name as listed in the the Contact Section (First, Middle, Last)

Date(Required)

New Member Application

Contact Information

Practice Background

Claims and Other History

Coverage and Payment Options

Amount Due

Select Payment Method

Declaration, Acknowledgement, Authorization & Signature