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Home > Insurance Division > Doctors' Corner > MMLIPA Fund Application > Application Instructions
2006 Application Instructions   Medical Malpractice Liability Insurance Premium Assistance Fund
IMPORTANT: The 2006 Online Application Period ended August 24, 2007.
Who Could Apply?    

Only practitioners and healthcare providers, covered by medical malpractice liability insurance in 2006, whose primary practice area was in one of the specialties and subspecialties listed in Order A07-118 (PDF, 60K) were eligible to apply for the subsidy. Those specialties/subspecialties were:

  • Obstetrics/Gynecology - Practices otherwise limited to gynecology were excluded.
  • Neurosurgery
  • Diagnostic Radiology - Limited to radiologists who read mammograms. The radiologist must have been a New Jersey Board Certified or Board eligible radiologist and was certified as meeting the requirements under the Federal Mammography Quality Standards Act and regulations.
 

Please Note:

  • Only applications containing all the required information will be processed.

  • This application could not be updated once it was filed. Contact our staff at 609-292-3100.
     
IMPORTANT: You must have also submitted a State of New Jersey W-9 Questionaire Form at the time that you filed your online application. This questionaire must have been completed, signed and returned to the New Jersey Department of Banking and Insurance BEFORE you or your designated payee can receive the subsidy. Please complete the W-9 questionnaire, and fax the form to 609-777-0508. The W-9 form cannot be filed online. The person who will receive the subsidy payment (either you or your designated payee) should submit the W-9 Questionnaire form as soon as possible.

PLEASE NOTE:

Even if the Department of Banking and Insurance determines that you are eligible for this subsidy, the State Treasurer will not process our request for a payment to you (or your designated payee) without a W-9 on file with their office.

If you or your designated payee previously received a premium subsidy paid in either 2005 and/or 2006, another W-9 is not necessary for the 2006 premium subsidy paid in 2007. The New Jersey State Treasury office already has your payee information on file.

The W-9 form is NOT the 2006 Online Application.

Applications are no longer being accepted.

 
Detailed Instructions
To complete the Medical Malpractice Liability Insurance Premium Assistance Fund Application, you needed the following required information:
 
1. Your Complete 12-digit BME License Number that begins with either 25MA or 25MB and is followed by 8 numbers.
2.

Detailed Medical Malpractice Liability Insurance Premium policy information for all insurance policies issued or renewed in 2006, that included: 

  1. Insurer name
  2. Policyholder or insured's name and address (for the Applicant, Group Practice, Hospital or other named insured)
  3. Complete Policy Number
  4. Policy Dates (inception and expiration dates, ie: 01/01/2006 to 01/01/2007)
  5. Type of Policy (Claims Made, Occurrence, Tail, etc.)
  6. Limits of Liability

Note: If you were insured by more than one insurer in 2006, the application provided for additional insurer information.

If you were not the named insured on the policy or policies, you needed to obtain the above information from the named policyholder (ie: your employer, group practice, hospital, etc.) before proceeding with the application process.

3.

If you were not the named policyholder and another party or entity was paying the premium, you had the option of having the subsidy payment sent directly to a Designated Payee other than yourself. You needed to provide the Designated Payee's name, address, contact person, telephone number and FEIN or Tax ID Number. Designated Payees include Group Practices, Hospitals or other such employers. If you chose this option, it was very important to notify the Designated Payee that they need to complete the W-9 questionnaire and fax it to 609-777-0508, with a cover sheet containing your name and complete BME License number, for proper identification. The W-9 Questionnaire form should be submitted no later than Friday, August 24, 2007.

Note:
The State Treasurer cannot issue payment to the Designated Payee if there is no W-9 on file with their office. If you or your designated payee previously received a premium subsidy paid in either 2005 and/or 2006, another W-9 is not necessary for the 2006 premium subsidy paid in 2007. The New Jersey State Treasury office already has your payee information on file.

4. ALL information on the application is required (including social security number) except your e-mail address.

More Information View our Frequently Asked Questions
MMLIPA Fund
NJ Department of Banking and Insurance
PO Box 325
Trenton, NJ 08625-0325
Telephone: 609-292-3100


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Copyright © 2007, State of New Jersey
New Jersey Department of Banking and Insurance