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J.M. Woodworth is committed to our agents and we are working to make it easier for our agents to do business with us. The following online forms are available for download:

 

Form Number Description Purpose
JMW PCCMAR- FORM (07-07) - Specimen Paid Claims/Claims Made & Reported Coverage Form Policy Form
JMW PCCMAR DEC (07-07) - Specimen Paid Claims/Claims Made & Reported Declarations Page Used to Describe Coverage
JMW PCCMAR-P-T (07-07) - Specimen Part-Time Endorsement Utilized when an Insured works 20 hours or less per week.
JMW PCCMAR - PROF SVSC (07-07) - Specimen Professional Services Endorsement Identifies the Specialty and Medical Procedures that are covered under the policy.
JMW PCCMAR- SNI (07-07) - Specimen Scheduled Named Insureds Endorsement Applicable when there are more than one Named Insureds on one policy. Provides for separate limits of liability.
JMW PCCMAR - AI (07-07) - Specimen Additional Insured Endorsement Applicable to any person or organization who shares in the limit of liability with a Named Insured.
JMW PCCMAR - DCSR (07-07) - Specimen Disciplinary Claim Sub-limit Revision Endorsement Used on a group policy when a Scheduled Named Insured has a different Disciplinary Claim Sublimit than what is shown on the Declarations.
JMW PCCMAR - COL (07-07) - Specimen Change of Limits Endorsement Utilized when a Named Insured changes his/her limits during the policy period.
JMW PCCMAR - MED DIR (07-07) - Specimen Medical Directors Endorsement Amends Article III. P. which excludes Medical Directorship. This Endorsement adds coverage to the policy for medical directorship duties of the Named Insured at specific locations.
JMW PCCMAR LOC TEN (07-07) - Specimen Locum Tenens Endorsement Schedules a Locum Tenens for specific days in which he/she filled in for a Named Insured.
JMW PCCMAR - GC (07-07) - Specimen General Change Endorsement Utilized to amend any Article of the policy for additions or exclusions of coverage.
JMW PCCMAR - COP (07-07) - Specimen Cancellation of Policy Endorsement Utilized when the entire policy is being canceled by either the First Named Insured or the Company.
JMW PCCMAR - COI (07-07) - Specimen Cancellation of Insured Endorsement Utilized on group policies, where there is more than one Named Insured, to cancel coverage for a specified Named Insured.
JMW PCCMAR - ROP (07-07) - Specimen Reinstatement of Policy Endorsement Reinstates a policy that has been canceled.
JMW PCCMAR - ERPC (07-07) - Specimen Extended Reporting Period and Conversion Endorsement Utilized when a Named Insured executes the Extended Reporting Period Option.
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Form Number Description Purpose
JMW CMAR - Form (10-07) - Specimen Claims Made & Reported Coverage Form Policy Form
JMW CMAR - DEC (10-07) - Specimen Claims Made & Reported Declarations Page Used to Describe Coverage
JMW CMAR - P-T (10-07) - Specimen Part-Time Endorsement Utilized when an Insured works 20 hours or less per week.
JMW CMAR - PROF SVCS (10-07) - Specimen Professional Services Endorsement Identifies the Specialty and Medical Procedures that are covered under the policy.
JMW CMAR - SNI (10-07) - Specimen Scheduled Named Insureds Endorsement Applicable when there are more than one Named Insureds on one policy. Provides for separate limits of liability.
JMW CMAR - AI (10-07) - Specimen Additional Insured Endorsement Applicable to any person or organization who shares in the limit of liability with a Named Insured.
JMW CMAR - DCSR (10-07) - Specimen Disciplinary Claim Sublimit Revision Endorsement Used on a group policy when a Scheduled Named Insured has a different Disciplinary Claim Sublimit than what is shown on the Declarations.
JMW CMAR - COL (10-07) - Specimen Change of Limits Endorsement Utilized when a Named Insured changes his/her limits during the policy period.
JMW CMAR wSUB PCCMAR CF-ERP (10-07) - Specimen Substitution of Paid Claims/Claims Made & Reported Coverage Form Endorsement Used as an attachment to a Claims Made & Reported policy when the Insured has other exposure that was priced on a Paid Claims basis. This endorsement essentially states that other than the hospitals scheduled, which require Claims Made coverage, all other exposure that is not associated/affiliated with the scheduled hospitals is considered Paid Claims exposure.
JMW CMAR-PAA (10-07) - Specimen Premium and Audit Endorsement Applicable when the Substitution of Paid Claims/Claims Made & Reported Coverage Form Endorsement is included. Identifies the how the bifurcated premium was derived at the inception of the policy and explains the audit terms applicable at the end of the policy term.
JMW CMAR - MED DIR (10-07) - Specimen Medical Directors Endorsement Amends Article III. P. which excludes Medical Directorship. This Endorsement adds coverage to the policy for medical directorship duties of the Named Insured at specific locations.
JMW CMAR - LOC TEN (10-07) - Specimen Locum Tenens Endorsement Schedules a Locum Tenens for specific days in which he/she filled in for a Named Insured.
JMW CMAR - GC (10-07) - Specimen General Change Endorsement Utilized to amend any Article of the policy for additions or exclusions of coverage.
JMW CMAR - COP (10-07) - Specimen Cancellation of Policy Endorsement Utilized when the entire policy is being canceled by either the First Named Insured or the Company.
JMW CMAR wSUB PCCMAR CF-COP (10-07) - Specimen Cancellation of Policy Endorsement Utilized when the entire policy is being canceled by either the First Named Insured or the Company, AND where the Substitution of Paid Claims/Claims Made & Reported Coverage Endorsement is included.
JMW CMAR - COI (10-07) - Specimen Cancellation of Insured Endorsement Utilized on group policies, where there is more than one Named Insured, to cancel coverage for a specified Named Insured.
JMW CMAR wSUB PCCMAR CF-COI (10-07) - Specimen Cancellation of Insured Endorsement Utilized on group policies, where there is more than one Named Insured, AND where the Substitution of Paid Claims/Claims Made & Reported Coverage Endorsement is included, to cancel coverage for a specified Named Insured.
JMW CMAR - ROP (10-07) - Specimen Reinstatement of Policy Endorsement Reinstates a policy that has been canceled.
JMW CMAR - ERP (10-07) - Specimen Extended Reporting Period Utilized when a Named Insured executes the Extended Reporting Period Option.
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Microsoft Word 97-2007 Format Adobe PDF Format
App for Multi-Practice Clinic/Large Groups App for Multi-Practice Clinic/Large Groups
Bifurcated Paid Claims/Claims Made Questionnaire Bifurcated Paid Claims/Claims Made Questionnaire
Endorsement Request Form Endorsement Request Form
Extender New Business Application Extender New Business Application
Extender Renewal Application Extender Renewal Application
Locum Tenens Application Locum Tenens Application
Part Time Supplement Questionnaire Part Time Supplement Questionnaire
Physician/Surgeon New Business Application Physician/Surgeon New Business Application
Physician/Surgeon Renewal Application Physician/Surgeon Renewal Application
Plastic & Cosmetic Procedure Questionnaire Plastic & Cosmetic Procedure Questionnaire
Prior Acts Supplemental Application Prior Acts Supplemental Application
No Loss Warranty Letter No Loss Warranty Letter
Recovering Physician/Surgeons Questionnaire Recovering Physician/Surgeons Questionnaire
Request for Decreased Limits Request for Decreased Limits
Request for Increased Limits Request for Increased Limits
Supplemental Claims Questionnaire Supplemental Claims Questionnaire
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NYDOH Healthcare Proxy form (English)
NYDOH Healthcare Proxy form (Spanish)
OMH Authorization for Patient Interview form
OMH Authorization for Patient Photograph, Videotaping or other Visual Audio Image
OMH Authorization for Release of Information
OCA Authorization for Release of Health Information Pursuant to HIPAA
NYDOH Informed Consent to Perform HIV Testing
NYDOH HIPAA Compliant Authorization for Release of Medical Information and Confidential HIV Related Information
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