<h1>Prof Liability.pdf</h1><br/>PROFESSIONAL LIABILITY INSURANCE INFORMATION The following information is required from all students entering field. Please answer the following questions in order to be covered under the Texas Christian University’s blanket policy for professional liability coverage for social work students participating in internships. Please circle the correct responses. 1. Have you ever been convicted of or charged with a crime in any state or country, the disposition of which was other than acquittal or dismissal? YES NO If yes, give full particulars in order for the application to be considered. (Use a separate sheet) 2. Have you ever been required by any licensing board or professional ethics body to surrender their license or been found guilty of a violation of ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence in any state or country? YES NO If yes, give full particulars, and copies of charges, correspondence, and any findings in order for the application to be considered. 3. Are there any complaints, charges or investigations pending against you by any licensing board or professional ethics body for violations of ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence in any state or country? YES NO If yes, give full particulars, and copies of charges, correspondence and any findings in order for the application to be considered. 4. Have you ever had any insurance company or Lloyd’s decline, cancel refuse to renew or accept only on special terms any professional liability insurance? YES NO If yes, give full particulars in order for the application to be considered. 5. Has any professional liability claim or suit ever been made against you, your predecessors in business or against any past or present partner(s)? YES NO If yes, give full particulars and copies of any summons and complaints, pertinent correspondence and outcome, if any, for this application to be considered. 6. Are there any circumstances of which you are aware of that may result in any professional liability claim or suit being made against the school (TCU) or any person covered by this policy, their predecessors in business or against any past of present partner(s)? YES NO If yes, give full particulars in order for the application to be considered. 7. Are you currently, or have you ever been, engaged in any sexual misconduct with any current or former student or current or former patients (clients) or current or former patient’s (client’s) spouse or any person with a direct relationship to the patient (client) or former patient (client). For example, a guardian, blood relative of the patient of spouse or any person sharing the patient’s domicile. [Sexual misconduct means any actual or alleged erotic physical contact or attempt threat or proposal thereof.] YES NO If yes, give full particulars in order for the application to be considered. Please print your name Date Signature Return this form with your Application for Field Education. 8/01