Addiction Counselor Insurance
Malpractice Insurance for Addiction Professionals
The Van Wagner Group/Behavioral Health Management Corp./Behavioral Health Purchasing Group
Application for NAADAC Professional Liability Insurance
Please answer all questions. Incomplete applications will be returned to applicant.When you complete the form, please print, sign and mail the form as directed below.
IMPORTANT: This program does not cover physicians, licensed or certified clinical psychologists, pastoral counselors, registered nurses in the practice of their profession or hypnotherapists. It is intended for addiction counselors who are members of NAADAC. If you are not a member of NAADAC, call 800-548-0497 for a membership application.
PLEASE NOTE: YOU MUST LIST A PHYSICAL ADDRESS AND NOT A PO BOX.
(If you answered yes to any part of question 4, please note this individual policy does NOT cover your corporate entity or your employees. If you need a group application, call The Van Wagner Group at 800-735-1588)
** IMPORTANT **
If the state you are practicing in has mandatory license or certification requirements,you must be in compliance with those requirements or coverage could be in jeopardy.
You may add a municipality, government entity or similar organization that you have a contractual obligation to cover as an additional insured. You cannot add another individual or any corporation you own or for which you are a W-2 employee. The additional premium is $50 for additional insured.
This Professional Liability Insurance program has been organized as a purchasing group (Behavioral Health Purchasing Group Inc.) domiciled in Delaware, pursuant to legislations enacted by the U.S. Congress as the Federal Liability Risk Retention Act of 1986. You automatically become a member of the purchasing group once your completed application has been approved and your premium payment received. My signature below represents that all questions presented have been answered truthfully and correctly. The applicant understands that incorrect information could void the insurance coverage. Signing this form or rendering premium does not bind the applicant or company/underwriter to complete the insurance, but it is agreed that this form shall be the basis of the contract and shall form part of the policy, should a policy be issued. Any person who knowingly and with intent to defraud an insurance company files an application for insurance containing false information, or conceals information concerning any fact material hereto for the purpose of misleading, commits a fraudulent insurance act.
Notice to Arkansas Applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Notice to California Applicants: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to any 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 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.
Notice to Florida Applicants: Any person who knowingly and with the intent to injure, Defraud or Deceive any insurer files a Statement of Claim or an Application containing any False, Incomplete, or Misleading information is Guilty of a Third Degree Felony.
Notice to Idaho Applicants: Any person who knowingly and with the intent to Injure, Defraud or Deceive any insurer files a Statement of Claim or an Application containing any False, Incomplete or Misleading information is Guilty of a Felony.
Notice to Indiana Applicants: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.
Notice to Kentucky and New Jersey Applicants: Any person who knowingly and with intent to defraud an insurance company or other persons, files a 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, subject to criminal prosecution and civil penalties.
Notice to Minnesota Applicants: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Notice to Nevada Applicants: Pursuant to NRS 686A 291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete, or misleading information concerning a material fact is guilty of a felony.
Notice to New Hampshire Applicants: Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
Notice to New York Applicants: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Notice to Ohio Applicants: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Notice to Oklahoma Applicants: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Notice to Pennsylvania Applicants: 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.
Notice to Texas Applicants: Risks located in Texas that are insured through a purchasing group are not protected by an insurance insolvency guarantee fund in Texas and may not be subject to all insurance laws and regulations of that state.
Mandatory Initial Compensation Disclosure
As required by the New York State Insurance Department pursuant to Regulation 194
As an independent insurance agent or insurance broker The Van Wagner Group, a division of Sterling & Sterling, Inc may have access to more than one insurance company to place your coverage. Whether acting as an independent insurance agent or insurance broker we have certain obligations to you as the purchaser and certain obligations to the insurance company as determined by both statutory and case law. If acting as an independent insurance agent we may have authority to obligate the insurance company on your behalf and as a result we may be required to act within the scope of our contractual agreement with the company.
As the purchaser you need to understand that we typically will receive compensation from the insurance company based on the agreement we have with each company. That compensation may vary from company to company depending on certain factors. You may receive information about our compensation on the policy or policies you select and about any policies we have presented to you which you did not select by asking us for the information.
It is our privilege to act on your behalf. Please be sure to let us know if you have any questions.
The County you selected is within a state that charges tax. In order to be in compliance with state regulations, please verify the state that your county of practice resides.
The State of Kentucky also imposes a mandatory 1.5% Surcharge on the annual premium. In addition, each municipality in Kentucky imposes its own tax that is applied against the annual premium.
(*Student counselors are covered only for the counseling provided as a student under supervision. You must apply for regular coverage if you counsel outside your school activities.)
I understand that entering incorrect information in this application could void the insurance coverage. My electronic acceptance below represents that all questions presented have been answered truthfully and correctly. Submitting this form or rendering premium does not bind the applicant or company/underwriter to complete the insurance contract, but it is agreed that this form shall be the basis of the contract and shall form part of the policy, should a policy be issued.
Any person who knowingly and with intent to defraud an insurance company files an application for insurance containing false information, or conceals information concerning any fact material hereto for the purpose of misleading, commits a fraudulent insurance act.
I agree that my name as typed in the field below is equivalent to my signature on this document and I consent to conduct the transactions to which this document is applicable by electronic means, including the delivery of any documents to me.
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