Account Coordinator Assn
Resume:
Request for
Insurance Company Policy Limit Change
Section A – GENERAL INFORMATION
Section B – POLICY LIMIT CHANGE INFORMATION
(available only in CT)
LAST FIRST MIDDLE INITIAL
Section C – PLEASE READ, SIGN AND DATE
STREET CITY STATE ZIP
Page 1 of 2
Name: Mailing Address: Phone: Fax: Email Address: NCMIC Policy Number: Please increase/decrease the limits of liability on my NCMIC Professional Liability Insurance Policy to (check one):
$100,000/$300,000 $200,000/$600,000 $250,000/$750,000
$500,000/$1 million $500,000/$1.5 million $1 million/$3 million Reason for change request (required): Please fax me a copy of my declarations page showing the new limits (a copy will automatically be mailed to you). I hereby authorize NCMIC to change the limits of liability for my malpractice insurance coverage as indicated above. I understand that if I fax my request for a limit increase to NCMIC, this change will become effective on the following day if approved. All other changes will be made effective the same day if approved, unless I request otherwise. I am aware that all claims reported after the effective date of this limit change will be covered at the new limit of liability regardless of when the alleged incident occurred. Also, I have no knowledge of any claims or incidents of potential malpractice which may have occurred that I have not yet reported to any insurance carrier.
By signing this application, I certify and attest that the statements, information, and answers provided herein are true and accurate. I understand that NCMIC Insurance Company (NCMIC) shall rely upon the statements, information, and answers provided on this application to determine whether to accept this application for insurance and, if the application is accepted, to determine at what rate to insure. New Hampshire residents: By signing this application, I represent that the statements, information, and answers provided herein are true and accurate. I understand that NCMIC Insurance Company (NCMIC) shall rely upon the statements, information, and answers provided on this application to determine whether to accept this application for insurance and, if the application is accepted, to determine at what rate to insure. For Residents of all States Except Colorado, Maine, Maryland, Pennsylvania, Washington and District of Columbia: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto or knowingly helps with intent to defraud, commits a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. District of Columbia:WARNING: It is a crime to provide false, or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Maine and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Continued .
©2017 NCMIC NFL 814*-******
Your email address will never be sold. It will be used to send you important notices. Email
DocuSign Envelope ID: 03374D49-67F5-4522-8654-EC0FA63B94BB Anchorage
************@*****.***
X
907
Markian
AK
Babij
Required by an MCO.
A
830-3109
X
3500 Latouche St
ND054153
99508
X X SIGNATURE DATE
X X AGENT SIGNATURE DATE
Section D – RETURN THIS FORM
Mail to:
NCMIC Insurance Company
P.O. Box 9118
Des Moines, IA 50306
Fax to:
Scan and email to:
***********@*****.***
Questions? Call toll free
The Naturopathic Malpractice Insurance Plan is offered through NCMIC Diversified Health RPG Assn. Coverage is underwritten by NCMIC Insurance Company.
©2017 NCMIC NFL 814*-******
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Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Section C – PLEASE READ, SIGN AND DATE (CONTINUED) 4/1/2021
DocuSign Envelope ID: 03374D49-67F5-4522-8654-EC0FA63B94BB 4/1/2021
Certificate Of Completion
Envelope Id: 03374D4967F545228654EC0FA63B94BB Status: Completed Subject: Please DocuSign: Markian Babij ND054153 Limit Change Request Eff 07-01-17.pdf Source Envelope:
Document Pages: 2 Signatures: 1 Envelope Originator: Certificate Pages: 5 Initials: 0 Ashley LaFollette AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-06:00) Central Time (US & Canada)
14001 University Ave
Clive, IA 50325
***********@*****.***
IP Address: 140.82.186.130
Record Tracking
Status: Original
4/1/2021 12:54:51 PM
Holder: Ashley LaFollette
***********@*****.***
Location: DocuSign
Signer Events Signature Timestamp
Markian Babij, ND
************@*****.***
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Using IP Address: 66.230.110.250
Sent: 4/1/2021 12:55:42 PM
Viewed: 4/1/2021 12:57:18 PM
Signed: 4/1/2021 12:57:38 PM
Electronic Record and Signature Disclosure:
Accepted: 3/30/2021 4:17:59 PM
ID: cf4942ea-a936-45d6-81fe-b4a4e0bc7884
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Account Coordinator
***********@*****.***
Security Level: Email, Account Authentication
(None)
Sent: 4/1/2021 12:57:38 PM
Electronic Record and Signature Disclosure:
Accepted: 3/9/2021 1:58:19 PM
ID: 83c755c2-6396-41d3-885d-1f5bea0b0bf3
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 4/1/2021 12:55:42 PM Certified Delivered Security Checked 4/1/2021 12:57:18 PM Signing Complete Security Checked 4/1/2021 12:57:38 PM Completed Security Checked 4/1/2021 12:57:38 PM
Payment Events Status Timestamps
Electronic Record and Signature Disclosure
Electronic Transactions — Disclosure and
Consent Agreement
This consent agreement gives NCMIC Group, Inc. and its subsidiaries, affiliates, and related companies [*] (collectively, "NCMIC Group"), “We�, “Us�, your consent to conduct business electronically and electronically receive all disclosures and notices that we are legally required to provide to you. Below are the terms and conditions for conducting business electronically with us and receiving electronic notices and disclosures from us. Please read the information below carefully and thoroughly. If you can access this information electronically to your satisfaction and agree to these terms and conditions, please confirm your agreement by clicking the †I agree’ button at the bottom of this document. You understand, prior to consenting, that:
i. Your consent applies to electronic receipt of all notices and disclosures that we are legally obligated to provide to you, sending and receiving electronic documents, and using electronic signatures. Transactions that will be conducted electronically include, but are not limited to, the following:
a. Receiving insurance quotes;
b. Submitting applications for insurance coverage and/or financial products and services;
c. Receiving information and notices about your insurance policies; d. Receiving information and notices about your financial products and services; and e. Receiving billing information.
ii. Unless you consent, you have the right to receive all legally-required notices and disclosures on paper or in nonelectronic form;
iii. Even after consenting, you have the right to receive a paper copy of a notice or disclosure in addition to an electronic copy. You can obtain one paper copy, free of charge, by sending a request to the email address listed below; iv. You can withdraw your consent at any time through the DocuSign system or by sending a withdrawal request to the email address listed below; v. By consenting, you agree to provide us with your current e-mail address and update us as to any changes; and
vi. We reserve the right to provide any disclosures and notices and conduct any other transactions on paper, rather than electronically. Requesting Paper Copies
At any time, you may request to receive a paper copy of any electronic document we provide to you. To request delivery of paper copies, you must send us an e-mail to *****@*****.***. You must state your email address, full name, US Postal address, telephone number, and document you are requesting in the body of the email request. Withdrawing Your Consent
You may withdraw your consent to conduct business with us electronically by doing one of the following:
i. Decline to sign a document within your DocuSign session, and use the †Withdraw Consent� form on the signing page of the DocuSign envelope; or ii. Send us an e-mail to *****@*****.***, and in the body of the request, state your e-mail, full name, US Postal Address, and telephone number. We do not need any other Electronic Record and Signature Disclosure created on: 12/1/2015 10:46:43 AM Parties agreed to: Markian Babij, ND, Account Coordinator information from you to withdraw consent.
Upon withdrawing your consent, you will no longer be able to receive required notices and disclosures electronically or conduct other transactions with us electronically. Withdrawing your consent to conduct business electronically may increase the time we take to process your transactions with us.
Accessing Electronic Documents and the Electronic Signature System You will have the ability to download and print documents we send to you through the DocuSign system during and immediately after a signing session. If you elect to create a DocuSign signer account, you may access the documents for a limited period of time (usually 30 days) after the documents are first sent to you.
Updating Your Contact Information
It is your responsibility to maintain and provide us with a current email address. To inform us of any changes to your email address, you must send an email message to us at *****@*****.***, and in the body of the request, you must state your previous email address and your new email address. We do not require any other information from you to change your email address. You must also notify DocuSign of changes to your email address by following the process for changing email in the DocuSign system.
Minimum Software and Settings Requirements
Software and
Settings
Requirements
Operating
Systems
Windows Vista® and above; Mac OS® X; AndroidTM; IOS® Browsers Final release versions of Internet Explorer® 9.0 or above (Windows only); Mozilla Firefox 33 or above (Windows and Mac); Safari TM 6.2 or above (Mac only); Chrome 32 and above (Windows and Mac)
PDF Reader Acrobat® or similar software may be required to view and print PDF files Screen
Resolution
1024 x 768 minimum
Enabled
Security
Settings
Allow per session cookies
** These minimum requirements are subject to change. If these requirements change, we will provide you with the revised requirements and ask you to reaccept the terms and conditions of this disclosure. Pre-release (e.g. beta) versions of operating systems and browsers are not supported.
Acknowledging Your Access and Consent to Receive Materials and Conduct Business Electronically
This document is similar to other electronic documents that we will provide to you. To confirm that you can access this information electronically and that you consent to conducting business with us electronically pursuant to the terms and conditions described above, please click the †I agree’ button below.
By checking the "I agree" button, you confirm that:
• You can access and read this ELECTRONIC TRANSACTIONS - DISCLOSURE AND CONSENT AGREEMENT document; and
• You can print this document on paper or save or send it to a place where you can print it, for future reference and access; and
• You agree to the terms and conditions above, and your consent to conduct business electronically continues until or unless you notify us as described above.
[*] Subsidiaries and affiliates : NCMIC Insurance Company; NCMIC Finance Corporation; NCMIC Finance Corporation of California; NCMIC Insurance Services, Inc.; Professional Solutions Insurance Company (in California PSIC Insurance Company); Professional Solutions Insurance Services, Inc.; PSFS 3 Corporation; Sextant Investment Advisors, LLC Related companies : NCMIC Risk Retention Group, Inc.
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