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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 6142 (September 30, 2023).

31 Pa. Code § 242.6. Reporting forms and procedures.

§ 242.6. Reporting forms and procedures.

 (a)  The following forms have been promulgated or approved for use under this chapter:

   (1)  Form 5116Acknowledgment of Insurance and Surcharge Paid. This form is intended as the acknowledgment from approved self-insured health care providers that they are self-insured in compliance with the act and have paid the Fund surcharge. Basic coverage insurance carriers may also use this form in lieu of the Declarations Page to acknowledge that the health care provider has purchased basic coverage professional liability insurance and paid the Fund surcharge, if prior approval for its continued use has been obtained from the Fund’s legal counsel in accordance with paragraph (2)(iii).

     (i)   The original of the form or the Declarations Page—whichever is applicable—is to be mailed to the health care provider; and a copy is to be submitted to the Fund, accompanied by the surcharge payment and Form 216, within 60 days of the effective date of the policy or self-insurance period.

     (ii)   Licensed physicians and podiatrists covered under policies issued to hospitals, nursing homes and primary health centers shall also be provided with a completed acknowledgment form. Individual copies of the form or the Declarations Page—whichever is applicable—accompanied by the surcharge payments for each of these health care providers and Form 216 are to be submitted to the Fund attached to the acknowledgment form applicable to the hospital, nursing home or primary health center.

   (2)  Declarations PageAcknowledgment of Insurance and Surcharge Paid. A copy of this form, which forms a part of the medical malpractice policy issued by a commercial carrier, shall be submitted to the Fund in lieu of and in the same manner as Form 5116 as explained in paragraph (1).

     (i)   The Declarations Page shall display all of the following:

       (A)   Information requested on the Form 5116, explained in paragraph (1).

       (B)   The amount of surcharge paid.

     (ii)   The copy to be submitted to the Fund shall be marked, ‘‘Catastrophe Loss Fund,’’ at the bottom of the form.

     (iii)   The Declarations Page shall be submitted to the legal counsel of the Director for approval prior to use. After July 1, 1980, no form will be accepted from a commercial carrier unless circumstances preclude the use of the Declarations Page, and prior approval for the continued use of the Form 5116 has been obtained from the legal counsel of the Director. Requests for approval shall be submitted to: Legal Counsel; Post Office Box 12030; 221 North Second Street; Harrisburg, Pennsylvania 17108.

   (3)  Form 216Remittance Advice. This form is to be used by basic professional liability insurance carriers and approved self-insurers for summarizing surcharges collected, payable and refundable. The form, accompanied by a check, should be received in the Director’s Office within 60 days from the effective date of the policy. On installment policies, the surcharge applicable to the full annual policy period shall be collected and remitted to the Director at the inception of the policy.

   (4)  Form C416Insurance Company Report. This completed form shall be submitted by the insurer or self-insurer to the Director, as notice to the Fund of claims reasonably believed to exceed the coverage of the insurer or the retained limits of the self-insured.

 (b)  Forms may be reproduced as necessary to facilitate compliance with this chapter.

 (c)  Upon written request, the Director may approve, in writing, modifications of the forms and procedures listed in subsection (a) if more expedient alternatives are available.

 (d)  Reporting forms submitted to the Fund erroneously completed will be returned to the commercial carrier or self-insured health care provider for correction and resubmission at the discretion of the Director. Surcharge payments that originally accompanied forms to be resubmitted will be returned only when circumstances render retention impracticable.

 (e)  Notwithstanding subsection (a), in the event that a health care provider is notified by the Fund of its noncompliance with the act’s insurance requirements and insurance is purchased under the notice, the health care provider shall disclose this fact to the insurer; and the insurer shall submit the reporting form and remit the surcharge within 30 days of the effective date of the policy.

 (f)  The emergency surcharge shall be reported to the Fund by the insurer or self insurer utilizing the same forms used when reporting the annual surcharge to the Fund. The forms used when reporting the emergency surcharge shall clearly indicate that it is the emergency surcharge being reported.


   The provisions of this §  242.6 issued under sections 206 and 506 of The Administrative Code of 1929 (71 P. S. § §  66 and 186); and sections 701(e)(4) and 702(a) of the Health Care Services Malpractice Act (40 P. S. § §  1301.701(e)(4) and 1301.702(a)).


   The provisions of this §  242.6 adopted October 15, 1976, effective October 16, 1976, 6 Pa.B. 2565; amended October 7, 1977, effective October 8, 1977, 7 Pa.B. 2894; renumbered February 9, 1979, 9 Pa.B. 498; amended April 25, 1980, effective April 26, 1980, 10 Pa.B. 1665; amended July 16, 1982, effective July 17, 1982, 12 Pa.B. 2282; amended October 8, 1982, effective October 9, 1982, 12 Pa.B. 3640; amended September 30, 1983, effective October 1, 1983, 13 Pa.B. 2969; amended through April 27, 1984, effective April 28, 1984, 14 Pa.B. 1453. Immediately preceding text appears at serial pages (85380) to (85383).

Notes of Decisions

   These provisions provide for resolution of complaints of adverse agency action, and as such, do not provide adequate remedy or preclude litigant from seeking relief in court, where issue is Cat Fund’s failure to pay share of malpractice claim settlement, which places Fund in position of defendant, as opposed to its designed position of participant and/or arbiter. Ohio Cas. Group of Ins. Companies v. Argonaut Ins. Co., 525 A.2d 1195 (Pa. 1987).

Cross References

   This section cited in 31 Pa. Code §  242.2 (relating to definitions); 31 Pa. Code §  242.5 (relating to adjustment of surcharge); 31 Pa. Code §  242.7 (relating to discontinuation of basic coverage insurance and notices of noncompliance); 31 Pa. Code §  242.10 (relating to self-insurers); 31 Pa. Code §  245.6 (relating to remittance of emergency surcharge amounts); and 31 Pa. Code §  245.7 (relating to reporting forms).

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