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Airiahem30 W <br />Please answer the faltowing gaestions "yes" ar."na." if you ariswer "yes," p2ease pravide fO details on segarate sleet <br />A. Has your malpractice ins ce ever been terminated or revoked except with your consent or request? <br />Yes ? No <br />B. Are you currentiy under 'nvesrigation by any government agenc? <br />Yes ? No <br />C. Have you been expelled or suspended from receiving payment under Medicare or Medicaid? <br />Yes ? No ? <br />D. Has your accreditarion sta s ever been reduced, terminated, suspended or revoked? <br />Yes ? No . / <br />E. Is your malpractice insurance provided throuah a self-insurance trust or progr~am? Yes ? No <br />If yes, an officer of the company (i.e. President, Vice-President, Chief Financial Officer or' Chief Operating Officer) must sign the <br />following attestarion. On behaif of the appiicant I represent and wamant the foliowing with respect to the self-insurance program <br />maintained by the applicant, or which provides professional liability insurance for the applicant: <br />1. The self insurance program is adequately funded to pmvide the minimum required limits of liabiliry as requued by Plan, and; <br />2. The self-insurance program has an actuarially validated reserve adequate for incurred claims, for incurred but aot reported <br />claims, aad future claims based on past experience, and; <br />3. The self insurance program has a designated third party administrator or other appropriately licensed claims professional or <br />attomey serving the pr ogram, and; <br />4. The self insurance program has a designated medical malpraotice defense firm, or more than one designated medical <br />malpracrice defense fum, aud; <br />5. The self insurance maintains excess insurance/reinsurance above the self funded level, if the self-insured level alone is . <br />insufficient to meet PIan's required limits, and; <br />6. The self insurance program maintains evidence of a surety bond or letter of credit as collateral to the self-insured -limit, or a <br />captive, self management of a lazJe retention throngh a trust, and; <br />7. The seif insurance maintains a total value of the pr ogratn that at a minimum meets the required limit of liability as set forth by <br />PIan? <br />8. I have confirmed the fqregoinhwith <br />Attest: <br />Name: <br />Title: <br />or the actuary for the self-insurance fund. <br />k, <br />1V OTE: The Plan reserves the right to request documentation from the applicant to confirm the information maintained in this <br />attestation. <br />Facility Application -10/03; revised 12/05, 7/06, 9/05 Page 2of 3