Binder Agreement

As an applicant to be a Participating CosmetAssure Surgeon, I ratify and affirm that I understand and agree that:

1. ALL of my patients, having one or more the Covered Procedures listed below, MUST be enrolled in CosmetAssure – neither the surgeon nor the patient can decline coverage.
2. CosmetAssure applies only to those patients whose original procedure requires general anesthesia or IV sedation.
3. Representatives of the insurer have the right to review and audit any records and/or records of the policyholder that may have a bearing on this insurance. This would include but is not limited to any individual patient file and/or a CPT-4 report and/or similar type of report.
4. The above-mentioned audit is to ensure there is compliance with the CosmetAssure program policy provisions. If the audit determines that any patients were not reported and paid by the surgeon as required, then premium must be paid within 30 days.
5. Patients not registered with CosmetAssure are not eligible for CosmetAssure benefits.
6. There is no coverage in effect prior to the policy’s effective date.

I hereby declare that the above statements are true and that I have not knowingly suppressed or misstated any material facts. I authorize the Company to conduct any investigation to substantiate this information. I hereby agree that this questionnaire including my attachments thereto shall be the basis of any insurance contract issued.

I agree to notify CosmetAssure if there is any future material change in any answer to this questionnaire, including without limitation, any change in my professional specialty, affiliation, or working arrangement with any other physician, firm or professional association.

I understand and agree that the completion of this questionnaire does not bind the Company to issue, nor me to purchase, a contract of insurance, provided however, if I am issued insurance by the Company and I purchase such contract of insurance, I understand and agree that any material misrepresentation or omission by me in this questionnaire may act to void such contract of insurance and may give the Company a right to rescind such contract.

I understand and agree to abide by the CosmetAssure Terms and Conditions.

See list of Covered Procedures here.