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Application7.aspx
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Application7.aspx
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<%@ Page Language="C#" AutoEventWireup="true" CodeFile="Application7.aspx.cs" Inherits="Application7" %>
<%@ Register TagPrefix="MaskedInput" Namespace="MaskedInput" Assembly="MaskedInput" %>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head id="Head1" runat="server">
<title>ePMS | electronic Policy Manager Solution</title>
<link rel="stylesheet" href="css/jquery-ui-1.7.2.custom.css" type="text/css" />
</head>
<script type="text/javascript" src="js/jquery-1.3.2.min.js"></script>
<script type="text/javascript" src="js/jquery-ui-1.7.2.custom.min.js"></script>
<script type="text/javascript">
</script>
<body background="Images2/SQUARE.GIF" bottommargin="0" leftmargin="0" rightmargin="0"
topmargin="19">
<form id="form1" runat="server">
<div>
<table id="Table8" align="center" bgcolor="white" border="0" cellpadding="0" cellspacing="0"
datapagesize="25" style="z-index: 139; left: 4px; width: 921px; position: static;
top: 4px; height: 1px" width="921">
<tr>
<td colspan="3" style="width: 764px; height: 1px">
<p>
<asp:PlaceHolder ID="Placeholder1" runat="server"></asp:PlaceHolder>
</p>
</td>
</tr>
<tr>
<td align="right" colspan="1" rowspan="5" style="font-size: 10pt; width: 5px; position: static;
height: 396px" valign="top">
<p align="center">
<asp:PlaceHolder ID="phTopBanner1" runat="server"></asp:PlaceHolder>
</p>
</td>
<td align="center" style="font-size: 0pt; width: 86px; height: 396px">
<p align="center">
<table id="Table9" bgcolor="white" border="0" cellpadding="0" cellspacing="0" style="width: 819px;
height: 64px" width="819">
<tr>
<td align="center" style="font-size: 0pt; width: 815px; height: 3px">
</td>
<td align="right" colspan="3" style="font-size: 0pt; height: 3px">
</td>
</tr>
<tr>
<td align="left" style="font-size: 0pt; width: 815px; height: 7px">
<table id="Table10" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 12px" width="808">
<tr>
<td align="left">
<asp:Label ID="Label21" runat="server" CssClass="headForm1 " Font-Bold="True" Font-Names="Tahoma"
Font-Size="11pt" ForeColor="Black" Height="16px" Width="92px">Application:</asp:Label>
<asp:Label ID="lblTaskControlID" runat="server" CssClass="HeadField" Font-Names="Tahoma"
Font-Size="9pt" Width="124px"></asp:Label></td>
<td>
</td>
<td align="right">
<asp:Button ID="btnPrevTop" runat="server" BackColor="#400000" BorderColor="#400000"
BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="< Prev"
Width="54px" TabIndex="1" OnClick="btnPrevTop_Click" />
<asp:Button ID="btnNextTop" runat="server" BackColor="#400000" BorderColor="#400000"
BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="Next >"
Width="54px" TabIndex="2" OnClick="btnNextTop_Click" />
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td style="font-size: 0pt; width: 815px" valign="top">
<table id="Table11" bgcolor="indigo" border="0" bordercolor="#4b0082" bordercolordark="#4b0082"
bordercolorlight="#4b0082" cellpadding="0" cellspacing="0" height="1" style="width: 808px"
width="808">
<tr>
<td>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="right" colspan="1" style="font-size: 5pt; width: 815px; height: 17px"
valign="top">
</td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td style="font-size: 0pt; width: 815px; height: 19px">
<table id="Table13" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" colspan="2">
<asp:Label ID="Label9" runat="server" Width="754px" Font-Size="9pt" Font-Names="Tahoma"
Font-Bold="True" CssClass="headform3">IX. STAFF PRIVILEGES/MANAGED CARE ORGANIZATION ACTIONS OR INVESTIGATIONS</asp:Label>
</td>
</tr>
<tr style="height: 5px">
<td align="left" colspan="2">
<table id="Table18" border="0" cellpadding="0" cellspacing="0" style="width: 100%;
height: 1px">
<tr style="height: 5px">
<td>
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 100%">
<asp:Label ID="Label35" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt">62. Have you ever had any hospital or surgical outpatient privileges denied, suspended, revoked, restricted, reduced, not renewed, proctored, or modified in any way?</asp:Label>
</td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
<asp:RadioButtonList ID="rdoMca62" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="55">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
</table>
</td>
</tr>
<tr style="height: 5px">
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px">
<asp:Label ID="Label39" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">63. Have you ever been investigated by any entity which as its principal activity is a health care service plan, third party administrator, or other business or organization arranging for the provisionof health services, or by any entity or organization providing or responsible for the provision of health care services, including any medical corporation, independent practice association, preferred provide organization, physician panel, or other entity or arrangement entering into agreements with third party payors for the provision of medical care, for the purpose of disciplining you or limiting, revoking or suspending your continued exercise, maintenanceor renewal right or entitlement to provide medical or surgical care to persons receiving health care arranged or rendered by such entity or organization?</asp:Label>
</td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
<asp:RadioButtonList ID="rdoMca63" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<asp:Label ID="Label1" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">if yes, please furnish details, including facility or managed care organization name, dates, allegations, circumstances, and outcome on your letterhead.</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
</td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="2">
<asp:Label ID="Label2" runat="server" Width="754px" Font-Size="9pt" Font-Names="Tahoma"
Font-Bold="True" CssClass="headform3">X. GOVERNMENTAL ACTION</asp:Label>
</td>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<asp:Label ID="Label3" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">64. Have you ever been investigated as the subject of, charged with or convicted of a misdemeanor or felony?</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
<asp:RadioButtonList ID="rdoMca64" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<asp:Label ID="Label4" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">65. Have you ever entered a "no contest" plea to a crime, other than a traffic violation?</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
<asp:RadioButtonList ID="rdoMca65" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<asp:Label ID="Label5" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">If you answered yes to question 64 or 65, please furnish full details on your letterhead, incluiding the following information:</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<table style="width: 99%">
<tr>
<td style="width: 900px">
<asp:Label ID="Label6" runat="server" Width="720px" Font-Size="9pt" Font-Names="Tahoma"
Font-Bold="False" CssClass="headform3">1. The nature of the investigation, the charge made or entered against you and the date and jurisdiction in which it was made or entered;</asp:Label>
</td>
</tr>
<tr>
<td style="width: 900px; height: 18px;">
<asp:Label ID="Label7" runat="server" Width="720px" Font-Size="9pt" Font-Names="Tahoma"
Font-Bold="False" CssClass="headform3">2. The susbstance of the investigation or allegations made or entered in the charge;</asp:Label>
</td>
</tr>
<tr>
<td style="width: 900px; height: 16px;">
<asp:Label ID="Label8" runat="server" Width="720px" Font-Size="9pt" Font-Names="Tahoma"
Font-Bold="False" CssClass="headform3">3. The manner in which the investigation or charge was resolved(i.e., dismissal, conviction, etc.)</asp:Label>
</td>
</tr>
<tr>
<td style="width: 900px">
<asp:Label ID="Label10" runat="server" Width="720px" Font-Size="9pt" Font-Names="Tahoma"
Font-Bold="False" CssClass="headform3">4. Any additional information concerning the investigation of charge as you may deem appopriate.</asp:Label>
</td>
</tr>
</table>
</td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
</td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<asp:Label ID="Label11" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">66. Have you ever been investigated by any state or federal regulatory or specialty society?</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
<asp:RadioButtonList ID="rdoMca66" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<asp:Label ID="Label12" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">67. Has any governmental agency ever suspended, revoked, restricted, placed you on probation, or taken any other action against your medical or narcotics license?</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
<asp:RadioButtonList ID="rdoMca67" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<asp:Label ID="Label13" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">If you answered yes to question 66 or 67, please furnish full details on your letterhead, incluiding the following information:</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<table style="width: 135%">
<tr>
<td style="width: 800px">
<asp:Label ID="Label14" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">1. The reason for the investigation, suspension, restriction, termination, curtailment, revocation, or non-renewal of your license, and/or the disciplinary action;</asp:Label>
</td>
</tr>
<tr>
<td style="width: 800px;">
<asp:Label ID="Label15" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">2. The susbstance of both the allegations and findings in any such action, proceeding, hearing or procedures involving the suspension, restriction, termination, curtailment, revocation, or non-renewal of your license, and/or disciplinary action;</asp:Label>
</td>
</tr>
<tr>
<td style="width: 800px;">
<asp:Label ID="Label16" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">3. The date of the suspension, restriction, termination, curtailment, revocation, or non-renewal of you license, and/or the disciplinary action; the full name of the licensing agency and its complete address;</asp:Label>
</td>
</tr>
<tr>
<td style="width: 800px">
<asp:Label ID="Label17" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">4. Any additional information concerning such action, proceedings, hearing, or procedure as you may deem appropriate.</asp:Label>
</td>
</tr>
</table>
</td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
</td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="2">
<asp:Label ID="Label18" runat="server" Width="244px" Font-Size="9pt" Font-Names="Tahoma"
Font-Bold="True" CssClass="headform3">XI. HEALTH</asp:Label>
</td>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<asp:Label ID="Label19" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">68. Have you ever been evaluated or recommended for tratment for, diagnosed with, or treated for alcohol, narcotics or any other substance abuse, sexual addiction or mental illness?</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
<asp:RadioButtonList ID="rdoMca68" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 21px">
<asp:Label ID="Label20" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="632px">69. Are you being treated for any medical condition, disease or illness that affect your ability to practice medicine?</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 21px">
<asp:RadioButtonList ID="rdoMca69" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 21px">
<asp:Label ID="Label26" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">If you answered yes to question 68 or 69, please furnish full details on your letterhead, incluiding the following information:</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 21px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<table style="width: 99%">
<tr>
<td style="width: 800px">
<asp:Label ID="Label22" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">1. The nature of the condition for which you sought treatment or consultation; the hospital or other institution at which yo were treated or consulted and its full address; the hospital or other institution with which you were affiliated at the time and its full address; the name of the individual with whom you were treated or consulted; the date(s) of treatment or consultation;</asp:Label>
</td>
</tr>
<tr>
<td style="width: 800px;">
<asp:Label ID="Label23" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">2. The name of the treatment or consultation and the recommended course for continuing treatment and consultation;</asp:Label>
</td>
</tr>
<tr>
<td style="width: 800px;">
<asp:Label ID="Label24" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">3. The manner in which the condition for which you were treated and consulted currently affects your day-to-day activities;</asp:Label>
</td>
</tr>
<tr>
<td style="width: 800px">
<asp:Label ID="Label25" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="612px">4. Any additional information concerning the treatment or consultation as you may deem appropriate.</asp:Label>
</td>
</tr>
</table>
</td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
</td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 34px">
<asp:Label ID="Label27" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="492px">70, Do you have any physical handicap or any chronic illness?</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 34px">
<asp:RadioButtonList ID="rdoMca70" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="2">
<asp:Label ID="Label28" runat="server" Width="428px" Font-Size="9pt" Font-Names="Tahoma"
Font-Bold="True" CssClass="headform3">XII. CLAIM HISTORY AND WARRANTY STATEMENTS</asp:Label>
</td>
</tr>
<tr>
<td align="left" colspan="2" style="width: 806px; height: 34px">
<asp:Label ID="Label29" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">NOTE: The word claim as used in nthis application refers to any demand for damages, resolved or pending,regardless of the result, arising from your professional activity and brought against you or any partner, associate, employee or profesional corporation or partnership, inluding any circumstances which have been brought to your attention by a patient or representative of a patient, in such a manner as to indicate the possibility of legal action against you or any partner, associate, employee or professional corporation or partnership.</asp:Label></td>
</tr>
<tr style="height: 5px">
</tr>
<tr>
<td align="left" colspan="2" style="width: 806px; height: 34px">
<asp:Label ID="Label30" runat="server" CssClass="headform3" Font-Bold="True" Font-Names="Tahoma"
Font-Size="9pt" Width="720px" Font-Italic="True">NOTE: If you answer Yes to any of the following questions, you must complete the attached incident/claims information form. You must complete a separate form for each incident or claim. Make copies of the form, if necessary.</asp:Label></td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 31px">
<asp:Label ID="Label31" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">71. Have you EVER been accused of sexual misconduct of any kind?</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 31px">
<asp:RadioButtonList ID="rdoMca71" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 27px">
<asp:Label ID="Label32" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">72. Have you EVER been involved in a malpractice claim or suit, either directly or indirectly?</asp:Label></td>
<td align="left" colspan="1" style="width: 429px; height: 27px">
<asp:RadioButtonList ID="rdoMca72" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="2" style="width: 806px; height: 34px">
<asp:Label ID="Label33" runat="server" CssClass="headform3" Font-Bold="True" Font-Names="Tahoma"
Font-Size="9pt" Width="720px" Font-Italic="True">It is agreed by all concerned that any such claim which, prior to the inception date of the proposed insurance, has been initiated against any person(s) proposed for this insurance, whether or not disclosed in this application, is excluded from coverage under the proposed insurance.</asp:Label></td>
</tr>
<tr style="height: 5px">
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px">
<asp:Label ID="Label34" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt">73. Are yoy aware of any of the following circumstances that might reasonably lead to a claim or suit being brought against you, even if you believe the claim or suit would be without merit:</asp:Label></td>
<td align="left" colspan="1">
</td>
</tr>
<tr>
<td align="left" colspan="2" style="width: 100%">
<table style="width: 100%">
<tr>
<td style="width: 1px; height: 15px;">
</td>
<td style="width: 806px">
<asp:Label ID="Label40" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt">(a) A request for records from a patient and/or attorney related to an adverse outcome?</asp:Label></td>
<td style="width: 100px; height: 15px;">
<asp:RadioButtonList ID="rdoMca73a" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList>
</td>
</tr>
<tr>
<td style="width: 1px">
</td>
<td>
<asp:Label ID="Label36" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">(b) A letter from an attorney regarding your medical treatment of a patient?</asp:Label></td>
<td style="width: 100px">
<asp:RadioButtonList ID="rdoMca73b" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList>
</td>
</tr>
<tr>
<td style="width: 1px">
</td>
<td>
<asp:Label ID="Label37" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">(c) Intra-operative or post-operative complications or other complications resulting in death, paralysis, or other significant disabilities?</asp:Label></td>
<td style="width: 100px">
<asp:RadioButtonList ID="rdoMca73c" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList>
</td>
</tr>
<tr>
<td style="width: 1px; height: 30px;">
</td>
<td>
<asp:Label ID="Label38" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">(d) Patient or family member dissatisfaction with the outcome or a procedure, treatment, or diagnosis?</asp:Label></td>
<td style="width: 100px; height: 30px;">
<asp:RadioButtonList ID="rdoMca73d" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList>
</td>
</tr>
<tr>
<td style="width: 1px; height: 30px">
</td>
<td style="width: 806px; height: 30px">
<asp:Label ID="Label41" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">(e) Any other circumstances that might reasonably lead to a claim or suit?</asp:Label></td>
<td style="width: 100px; height: 30px">
<asp:RadioButtonList ID="rdoMca73e" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
<tr>
<td style="width: 1px; height: 4px">
</td>
<td style="width: 800px; height: 4px">
<asp:Label ID="Label42" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma"
Font-Size="9pt" Width="720px">(f) If you answered Yes to any of the items (a) through (e) above, have these circumstances been reported to your current or prior professional liability carrier?</asp:Label></td>
<td style="width: 100px; height: 4px">
<asp:RadioButtonList ID="rdoMca73f" runat="server" Font-Names="Tahoma" Font-Size="9pt"
RepeatDirection="Horizontal" Width="80px" TabIndex="56">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList></td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="left" colspan="2" style="width: 806px; height: 34px">
<asp:Label ID="Label43" runat="server" CssClass="headform3" Font-Bold="True" Font-Names="Tahoma"
Font-Size="9pt" Width="768px" Font-Italic="True">It is agreed by all concerned that if such facts, circumstances, situations are known by any person(s) proposed for this insurance which would cause a reasonably prudent person to believe a Claim might be made, any Claim subsequently emanating therefrom shall be excluded from coverage under the proposed insurance.</asp:Label></td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 900px; height: 16px">
</td>
<td align="left" colspan="1" style="width: 429px; height: 16px">
</td>
</tr>
</table>
<table id="Table14" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td align="left" colspan="2" style="width: 606px; height: 3px">
</td>
</tr>
<tr>
<td align="left" colspan="1" style="width: 606px; height: 7px">
</td>
<td align="right" colspan="1" style="width: 429px; height: 7px">
<asp:Button ID="btnPrevBottom" runat="server" BackColor="#400000" BorderColor="#400000"
BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="< Prev"
Width="54px" TabIndex="57" OnClick="btnPrevBottom_Click" />
<asp:Button ID="btnNextBottom" runat="server" BackColor="#400000" BorderColor="#400000"
BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="Next >"
Width="54px" TabIndex="58" OnClick="btnNextBottom_Click" />
</td>
</tr>
<tr>
<td align="center" background="Images2/Barra3.jpg" colspan="2" style="width: 121px;
height: 3px">
</td>
</tr>
</table>
</td>
</tr>
</table>
</p>
<p>
</p>
<p>
</p>
<p>
</p>
<p>
</p>
<p>
</p>
<p>
</p>
</td>
</tr>
</table>
</div>
<MaskedInput:MaskedTextHeader ID="MaskedTextHeader1" runat="server"></MaskedInput:MaskedTextHeader><asp:Literal
ID="litPopUp" runat="server" Visible="False"></asp:Literal>
<input id="ConfirmDialogBoxPopUp" runat="server" name="ConfirmDialogBoxPopUp" size="1"
style="z-index: 102; left: 259px; width: 35px; position: absolute; top: 1669px;
height: 22px" type="hidden" value="false" />
</form>
</body>
</html>