:: VAUGHAN INS ::

CRSM: Clinical Research Site Management

I.Online Application/Questionnaire

Office use only

Thank you very much for applying for General/Professional Liability through your association as an CRSM member benefit .

Please note all members may not be eligible for this coverage.

Once your application has been completed and returned it will be submitted to an underwriter for review. Please take a moment to review the following description of operations listed hereunder which are used in determining primary eligibility for this program. If you have questions concerning whether your business practices meet these requirements please contact Mark Leal at 918-794-3881 or mark@vaughanins.com.

Regulatory Compliance Consulting and Clinical or Site Management Organization: Strategic Planning-Recruitment and Assembly, Trial Management, Trial Monitoring, Data Management, Analysis and Reporting, Protocol Preparation and Facilities Assessment. All Consulting Professional Services provided are required to comply with all laws and regulations at a local, state and federal government level in accordance with any and all Federal Regulatory Compliance requirements.

If it is determined that your work is outside the acceptable criteria for this program, please be assured that we will make every effort to obtain the very best coverage at the most affordable price with an alternate insurance provider.

Once your application has been approved by the company you will be notified via email from Vaughan Insurance Group. Attached to this notification will be an invoice for the annual premium. As soon as payment has been received, you will be provided a policy binder for 60 days indicating your coverage has been bound pending receipt of your policy from the insurance company. Also, any certificate of insurance requests will be sent at this time.

A. Requested Effective Date

Is "Prior Acts" coverage desired?	Yes No

*Please note that "Prior Acts" coverage is only available when your expiring policy is written on on a "claims made" form directly prior to purchasing this coverage. Coverage for "Prior Acts" will be provided for a(2) year term for a one time premium charge of 25% of the annual premium.

B. Applicant Information Section

Business Name
Mailing Address
City
State
Zip
Business Phone
Mobile Phone (optional)
Contact Name
FAX
Email
Website Address
Legal Entity
Other Legal Entity
Please enter your membership ID #

1. Number of years in business?

2. Number of years experience in your field of operations?

Are you a "Certified" member of your association? Yes No

Additional Information

If there are any operations or services listed on your website that are no longer
relevant or being offered by your company, please specify in the box below.

Please list other Professional Membership Affiliations:

Please list educational background

Please provide a brief description of your operations:

General Information

1. Is the applicant a subsidiary of another entity or does the applicant have any subsidiaries?	Yes No
If yes, please explain:

C. Loss History

1. Has any coverage been declined or cancelled within the last 3 years?

Yes No

If yes, please explain below.

2. To the best of your knowledge, currently are there any events or occurrences that may give rise to any claim within the last (3) years?

Yes No

Enter all occurrences, reserves or claims for the prior 5 years.

Check here if none

Date of Claim	Description of Claim	Amount Paid

D. Current Coverage(s)

Do you currently have Commercial General Liability Coverage?		Yes No
If Yes, please provide	Insurance Company Name:
	Effective Date of Coverage
	Policy Number:

Do you currently have Commercial Automobile Coverage?		Yes No
If Yes, please provide	Insurance Company Name:
	Effective Date of Coverage
	Policy Number:

Do you currently have Workers Compensation Coverage?		Yes No
If Yes, please provide	Insurance Company Name:
	Effective Date of Coverage
	Policy Number:

Do you currently have Excess/Umbrella Liability Coverage?		Yes No
If Yes, please provide	Insurance Company Name:
	Effective Date of Coverage
	Policy Number:

ELIGIBILITY FOR COVERAGE REQUIREMENTS

Does the Sponsor agree to indemnify the CRO?	Yes No
Do you request that the CRO be added as an "Additional Insured" to the Physician/Principal Investigators "Clinical Trial/Clinical Studies" policy? Understanding that some states may vary.	Yes No
Do you require and maintain a Certificate of Medical malpractice Insurance from all Physician /Principle Investigator's and have the certificates available for review by the insurance company?	Yes No
Do you require that the Physician/Principle Investigator show evidence that their medical malpractice policy provides coverage for "Clinical Trials/Clinical Studies" in their primary policy or provide an additional certificate of insurance indicating that this coverage has been obtained and is currently in effect elsewhere with another carrier?	Yes No
Are FDA approved protocols for each trial maintained and kept on file for review by the insurance carrier?	Yes No
Are informed consents for each trial maintained and kept on file for review by the insurance carrier?	Yes No
Are Nurses/Physicians Assistants required to carry their own Liability Insurance? This is Irrespective of whether they are an employee of CRO/SMO or of PI. They must maintain their own Liability Insurance	Yes No

All of the above questions must be answered "Yes" to be eligible for the coverage.

Anticipated Number of Trial Sites Annually	Anticipated Number of Trials Annually	Are subjects required to stay overnight?
		Yes No

Thank you for allowing Vaughan Insurance Group to service your insurance needs. It has been a pleasure serving you. Should you have any additional questions, please contact Mark Leal at (918) 794-3881 or mark@vaughanins.com.

* INFORMATION CONTAINED HEREIN TO THE BEST OF MY KNOWLEDGE IS ACCURATE AND COMPLETE

This application completed and submitted by:

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