General Practitioners, Dentists and Medical Practitioners other than Specialists Form

Medical Malpractice Insurance Proposal Form for General Practitioners, Dentists and Medical Practitioners other than Specialists

Part 1: General Section

Disclosure: 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 Section

Section A. Personal details of proposer

1. 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 Details

1. Telephone number*

2. Practice address*

3. Vat number (if applicable)*

4. HPCSA registration number*

5. How long have you been practicing?*

Section C: Professional credentials

1. Please state your relevant qualifications and experience*

Qualification(s)	Institution	Year 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 Has your membership with any Professional body ever been refused/suspended/ withdrawn or had special conditions imposed?*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 activities

1. Please confirm the percentage breakdown of the professional activities offered by you and for which you require cover:*

Professional Activity	Percentage (%)

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 Management

1. 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?

Section F: Insurance History

1. 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 Experience

1. 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/ incident	Date the claim/loss/complaint/ incident was made	Brief details of each claim/loss/ complaint/ incident	Total amount claimed	Total 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 Income

1. Please indicate the Gross taxable turnover for the relevant periods shown below:

Private practice*

Annual Gross income for the previous financial year	Annual Gross income estimated for the next financial year

Government practice*

Annual Gross income for the previous financial year	Annual Gross income estimated for the next financial year

2. Please indicate the % time spent in your Professional Capacity in:*

State Hospitals	Private Practice

%

3. How many hours a week do you spend in:*

State Hospitals	Private Practice

Hours

4. a) State your number of annual consultations:*

Previous Year	Current Year

4. b) State your number of annual consultations:*

Previous Year	Current Year

Section I: Insurance quotation required

1. 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

Addendum

Only applicable where the following disciplines are performed

Are you a:*

Procedural Practitioner
Non-procedural Practitioner

Aesthetic, Cosmetic, Dermatology and Plastics

Please 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 Orthodontics

Please indicate the breakdown of your procedures in an average year as follows:

Aesthetics and Cosmetic Dentistry

% split

Anaesthesia/Sedation

% split

Botox or other facial cosmetics

% split

General Dentistry

% split

Surgical Periodontal Treatment

% split

Implantology

% split

Oral Surgery

% split

Other (please specify)

% split