Medical Malpractice Insurance Proposal Form for General Practitioners, Dentists and Medical Practitioners other than Specialists ARE YOU A MEDICAL SPECIALIST? CLICK BELOW TO COMPLETE THIS FORM GET THE COVER YOU NEED Medical Malpractice Insurance Proposal Form Medical Malpractice Insurance Proposal Form for General Practitioners, Dentists and Medical Practitioners other than SpecialistsPart 1: General SectionDisclosure: medical practitioners / healthcare professionals You must disclose to Safire Insurance Company Limited (”the Insurer”) all information which is material to it in deciding whether to provide insurance cover to you, including any facts or conduct which might lead to a claim being made against you. Failure to do so could affect your cover. If you are in doubt, then rather disclose. If you do not understand any part of this document, please contact your broker prior to signing it. You will be bound by the answers which are given, and by the information provided by you in this proposal form. It is in your interests to make sure that all information is correct and understood. This proposal form will be submitted on your behalf to the Insurer, and has been compiled in such a manner as to provide the Insurer with as much detail as possible to enable the Insurer to evaluate the risk. Completion of this form does not bind either you or the Insurer to complete the insurance transaction. To assist the Insurer in accurately assessing liability for rating purposes, you are requested to answer all the questions. Where a mark is required, please mark the appropriate box with an “X”. Please answer ALL questions fully. Please note, replies such as “see your records”, or “as previously advised” are not acceptable. If the space provided is insufficient, a separate sheet should be attached. Part 2: Medical Malpractice SectionSection A. Personal details of proposer1. Name and surname* 2. ID number* 3. Mobile number* 4. Work number* 5. Country of permanent residence* 6. Email address* 7. Website* Section B. Practice Details1. Telephone number* 2. Practice address* 3. Vat number (if applicable)* 4. HPCSA registration number* 5. How long have you been practicing?* Section C: Professional credentials1. Please state your relevant qualifications and experience*Qualification(s)InstitutionYear Achieved 2. Has your membership with any Professional body ever been refused/suspended/ withdrawn or had special conditions imposed?* Yes No If YES, please provide details of the relevant circumstances*3. Do you regularly treat patients who are citizens of other countries who have travelled specifically to receive treatment from you?* Yes No If YES, please provide details on the type of care and the number of patients treated in the past 12 months.Section D. Insured's professional activities1. Please confirm the percentage breakdown of the professional activities offered by you and for which you require cover:*Professional ActivityPercentage (%) Up to 100%2. Should you perform any surgical procedures in an office-based setting (procedures performed under general, conscious sedation, spinal, or caudal anaesthesia) then please confirm what these procedures are below:*Section E: Practice Management1. a) Is it Mandatory that all your patients sign a consent for consultations? Yes No 1. b) Is it Mandatory that all your patients sign a consent for surgical procedures and / or theatre treatment?? Yes No 2. What is the current system you use to capture patient notes? Manual Capture Electronic Capture 3. How are your patient records secured? Hard copy Electronic format 4. How long do you retain patients' medical records? 5. Which of the following do you use for your internal risk management? Healthspace Medaware Medscape Up to Date Wordsure Section F: Insurance History1. Have you ever had a break in cover where you were not insured for a period of time?* Yes No 2. Have you had any break in clinical practice over the past 5 years?* Yes No If you answered YES to any of the above, then please give details.3. Are you currently or have been in the past insured for the type of insurance now being proposed?* Yes No If YES, then please confirm:Current Insurers Limit of Indemnity Excess Previous year’s premium Renewal date Retroactive date* (* only applicable if you were insured with a claims made policy in the past) Section G: Claims Experience1. Has any formal written complaint been made against you with any regulatory body, including the HPCSA, in your capacity as a medical practitioner?* Yes No 2. Has any disciplinary enquiry been initiated against you with any regulatory body, including the HPCSA, in your capacity as a medical practitioner?* Yes No 3. Has any monetary claim been made against you arising out of your professional conduct as a medical practitioner?* Yes No If you answered YES to any of the questions above, please give details below (attach a back page if necessary):Date of claim/loss/ complaint/ incidentDate the claim/loss/complaint/ incident was madeBrief details of each claim/loss/ complaint/ incidentTotal amount claimedTotal amount paid 4. Are you aware of any circumstances which might give rise to a claim against you which has not already been initiated?* Yes No If you answered YES, then please give details below.Section H: Fee Income1. Please indicate the Gross taxable turnover for the relevant periods shown below:Private practice*Annual Gross income for the previous financial yearAnnual Gross income estimated for the next financial yearGovernment practice*Annual Gross income for the previous financial yearAnnual Gross income estimated for the next financial year2. Please indicate the % time spent in your Professional Capacity in:*State HospitalsPrivate Practice%3. How many hours a week do you spend in:*State HospitalsPrivate PracticeHours4. a) State your number of annual consultations:*Previous YearCurrent Year4. b) State your number of annual consultations:*Previous YearCurrent YearSection I: Insurance quotation required1. Please indicate the amount of cover you require? (R)*2. Please indicate whether you currently pay your premium by way of:* A monthly debit order comprising of 10 equal instalments A monthly debit order comprising of 12 equal instalments A once off debit order comprising of a single installment A once off EFT comprising of a single installment AddendumOnly applicable where the following disciplines are performedAre you a:* Procedural Practitioner Non-procedural Practitioner Aesthetic, Cosmetic, Dermatology and PlasticsPlease indicate below which of the below aesthetic procedures you currently perform, (if any):Botox Injections Yes No Number performed Fillers Yes No Number performed Lipolytic Liposuction Yes No Number performed Sclerotherapy/ Smart Lipo Yes No Number performed Chemical peel Yes No Number performed Laser hair removal Yes No Number performed Threads Yes No Number performed Cosmetic Tattooing Yes No Number performed Laser wrinkle removal Yes No Number performed Permanent makeup Yes No Number performed Dentistry and OrthodonticsPlease indicate the breakdown of your procedures in an average year as follows:Aesthetics and Cosmetic Dentistry% splitAnaesthesia/Sedation% splitBotox or other facial cosmetics% splitGeneral Dentistry% splitSurgical Periodontal Treatment% splitImplantology% splitOral Surgery% splitOther (please specify)% splitGeneral PractitionersA&E or procedural (excluding scans and obstetrics)% splitAccident & Emergency% splitAesthetic or procedural (including scans, excluding obstetrics)% splitDetailed pregnancy scans% splitNon-procedural% splitAnaesthetics% splitIntrapartum obstetrics% splitObstetrics (full cover or limited deliveries)% splitAnaesthetics or assisting with deliveries% splitMinor procedures in rooms% splitProcedural% splitDeclarationI/We the undersigned duly authorised person(s) declare that: I am/we are authorised by each of the Insureds to sign this Proposal Form. The above statements are correct, true and complete. No information material to this Proposal Form has been withheld. I/we have read the important facts which you have put before me/us and I/we understand the advice given in relation to the duty of disclosure. I/we have diligently made all necessary and detailed enquiries in order to comply with the duty of disclosure. Apart from what is disclosed in this document, I/we are not aware of any request for records being made by a patient, family member of a patient, or an attorney nor have I/we received a letter from an attorney regarding treatment which was provided to a patient. Apart from what is disclosed in this document, I/we are not aware of any circumstance which might reasonably lead to a claim or suit being lodged against me, regardless of whether I/we view that suit to be without merit. I/we understand that no insurance is in force until such time as the Insurer has confirmed acceptance of the proposed insurance. I/we undertake to inform the Insurer of any material alteration to these facts occurring before completion of the contract of insurance. I/we acknowledge that the Insurer relies on the information and representations in this Proposal Form and otherwise made by me/us in relation to this insurance. I/we acknowledge that the signing of this proposal form binds neither myself to accept the subsequent quote, nor does it bind the Insurer to accept the proposal. It is agreed that all written statements and attachments furnished to the Insurer in conjunction with this proposal are hereby incorporated by reference into this proposal and made part thereof. Except where indicated to the contrary, I/we understand that any statement made in this Proposal Form will be treated by the Insurer as a statement made by all persons to be insured.I agree* Yes Date Month Day Year
