By typing my name in the E Signature box and checking the Confirm Signature box above, I certify that I was formerly insured by ISMIE Mutual Insurance Company before retiring from the practice of medicine.
I certify that I received an extended reporting period, or “tail,” from ISMIE Mutual Insurance Company. The limited coverage issued pursuant to this application will apply only to volunteer medical professional services rendered during the COVID-19 pandemic. Volunteer services are professional services for which I receive no compensation, except personal expenses incurred and reimbursed for providing volunteer services. Coverage will be provided by ISMIE Mutual Insurance Company.
The policyholder/member agrees to grant, assign, and give a proxy to the Board of Directors of ISMIE Mutual Insurance Company or their designee, for purpose of casting a vote at any and all meetings or in any and all instances in which a vote of the policyholder/members is required. It is understood that in the absence of any further action by the policyholder/member, this proxy shall remain valid and binding for the length of time which the policyholder/member shall continue to be a policyholder/member of ISMIE Mutual Insurance Company. It is further understood that on any given issue as to which the policyholder/member shall have a right to vote the policyholder/member may revoke this proxy, he, she or it may then vote in person or by written proxy at any meeting called for the casting of said vote. At the conclusion of said vote, this proxy, given to the ISMIE Mutual Board of Directors of its designee shall return to full force and effect and shall continue in full force and effect unless and until the policyholder/member elects to revoke this proxy for purposes of a future issue which may arise.
If an agent, by checking this box, I am authorized to submit this information on behalf of the insured and the information I have provided above is accurate to the best of my knowledge.