MC De Villiers - Non-Specialist Form - Genoa Underwriting Managers

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

X/Twitter

This field is for validation purposes and should be left unchanged.

Part 1 General Section

Disclosure(Required)

I agree to this disclosure.

Disclosure: Medical Practitioners / Healthcare Professionals

You must disclose to Lombard 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. 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.

Privacy and Sharing of Information

In order to provide you with appropriate insurance, the Insurer/Underwriting Management Agency may at times have to process/share your personal information. The processing of the information will at all times be in the interests of the Policyholder and may include sharing of your personal information with insurers, reinsurers, underwriting managers, brokers, financial institutions, industry bodies, credit agencies, and associated service providers (where applicable).

At all times, the sharing of such information is limited to only that information which will allow the Insurer/Underwriting Management Agency to provide you with suitable insurance/replacement insurance, to allow the Insurer/Underwriting Management Agency to process claims on your behalf, to allow the Insurer/Underwriting Management Agency to conduct surveys and marketing initiatives, to allow the Insurer/Underwriting Management Agency to correctly allocate premium payments, and to allow the Insurer/Underwriting Management Agency to share de-personalised data with our broker partners and appropriately authorised credit providers, in order to introduce policyholders to appropriate credit facilities and products.

We assure you that when the Insurer/Underwriting Management Agency shares your personal information with selected service providers/third parties, for the specific purposes outlined herein, we will ensure that the appropriate protections of your personal information are in place in accordance with our obligations under the Protection of Personal Information Act (POPIA). The Insurer/Underwriting Management Agency will take all reasonable steps to protect the personal information held in our possession against loss, unauthorised access, use, modification, disclosure, or misuse.

Consent and Agreement

By clicking "Agree" to this form, you:

Acknowledge that the personal information you supplied is provided voluntarily and that you consent to the processing of such information for the purposes of providing you with insurance and for lawful business reasons/purposes. You further acknowledge that this consent can be revoked by you at any stage via written notice to us.

Consent to your underwriting, claims, or credit information being retained on any shared database of the Insurer/Underwriting Management Agency whether your policy is active or has been cancelled.

Broker Name (should you not have a Broker, please insert N/A)(Required)

Part 2: Professional Indemnity and Medical Malpractice Section

Section A: Personal Details Of Proposer

1. Name and surname(Required)

2. ID number(Required)

3. Mobile number(Required)

4. Work number(Required)

5. Country of permanent residence(Required)

6. Email address(Required)

7. Website(Required)

SECTION B. Practice Details

1. Practice address(Required)

2. Telephone number(Required)

3. VAT number (if applicable)

4. Regulatory registration number(Required)

5. Practice Number (PCNS)(Required)

6. How long have you been practicing?(Required)

SECTION C. Professional credentials

1. Please state your relevant qualifications and experience(Required)

Qualification(s)

Institution

Year Achieved

2. Has your membership with any Professional body ever been refused/suspended/ withdrawn or had special conditions imposed?(Required)

YES

If YES, please provide details of the relevant circumstances.(Required)

3. Do you regularly treat patients who are citizens of other countries who have travelled specifically to receive treatment from you?(Required)

Yes

If YES, please provide details on the type of care and the number of patients treated in the past 12 months.(Required)

SECTION D. Insured’s professional activities

Please choose your specialty from the list below and fill in the corresponding questions.(Required)

Clinical Associates

Dentistry and Orthodontics

General Practitioners

Optometrists

Pharmacists

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

Professional Activity

Percentage (%)

Percentage (%) of 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:(Required)

3. Do you perform circumcisions and/or terminations of pregnancy?(Required)

Yes

If YES, please specify.

SECTION E. Practice Management

1a. Is it mandatory that all your patients sign consent for consultations(Required)

Yes

1b. Is it mandatory that all your patients sign consent for surgical procedures and/or in theatre treatment(Required)

Yes

2. What is the current system you use to capture patient notes?(Required)

Manual capture

Electronic capture

Other

3. How are your patient records secured?(Required)

Hard copy

Electronic format

Other

4. How long do you retain patients’ medical records?(Required)

5. Which of the following do you use for your internal risk management?(Required)

Healthspace

Medaware

Mediscape

Up to Date

Wordsure

Heidi Health

EMGuidance

None of the above

Other

Please specify(Required)

SECTION F. Insurance History

1. Are you currently or have been in the past insured for the type of insurance now being proposed(Required)

Yes

If YES, then please confirm:

Current Insurers

Limit of Indemity

Excess

Previous year's premium

Renewal date

Retroactive date*

* only applicable if you were insured with a claims made policy in the past

If YES, please upload your current schedule here:(Required)

Max. file size: 64 MB.

2. Have you ever had a break in cover where you were not insured for a period of time?(Required)

Yes

3 Have you had any break in clinical practice over the past 5 years?(Required)

Yes

If you answered YES to any of the above, then please give details.(Required)

SECTION G. Claims Experience

1. Have you notified any Insurer/s in the last 10 years of any potential notifications or circumstances that could possibly lead to a claim in your capacity as a medical practitioner?(Required)

Yes

If you answered YES, then please give details below(Required)

2. Has any formal written complaint been made against you with any regulatory body, including the HPCSA, in your capacity as a medical practitioner?(Required)

Yes

If you answered YES, then please give details below(Required)

3. Has any disciplinary enquiry been initiated against you with any regulatory body, including the HPCSA, in your capacity as a medical practitioner?(Required)

Yes

If you answered YES, then please give details below(Required)

4. Has any monetary claim been made against you arising out of your professional conduct as a medical practitioner?(Required)

Yes

If you answered YES to any of the questions above, please give details below (attach a back page if necessary):(Required)

Date of claim/ loss/Date of claim/ incident

Date the claim/loss/complaint/incident was made

Full details of each claim/loss/complaint/incident

Total amount claimed

Total amount paid

File(Required)

Max. file size: 64 MB.

5. Are you or anyone else in your organisation aware, after consultation with them, of any circumstance which might give rise to a claim against you which has not already been reported to your current provider?(Required)

Yes

If you answered YES, then please give details below.(Required)

SECTION H. Fee Income

1. Please confirm if you are an employee of the State?

Yes

If YES, please specify type of State employment:

Permanent

Seasonal

If YES has been selected for Permanent employee of the State, please provide us with your RWOPS agreement / certificate.

Upload you RWOPS agreement / certificate here(Required)

Max. file size: 64 MB.

2a. Please indicate the Gross taxable turnover for the relevant periods shown for private practice:(Required)

Annual Gross income for the previous financial year

Annual Gross income estimated the next financial year

2b. Please indicate the Gross taxable turnover for the relevant periods shown for government practice:(Required)

Annual Gross income for the previous financial year

Annual Gross income estimated the next financial year

2c. Please indicate the Gross taxable turnover for the relevant periods shown for Medico-legal Services:(Required)

Annual Gross income for the previous financial year

Annual Gross income estimated the next financial year

3. Please indicate the % time spent in your Professional Capacity in:(Required)

State Hospitals (%)

Private Practice (%)

The total % time between State and Private must equal 100%

4. How many hours a week do you spend in:(Required)

State Hospitals

Private Practice

5a. State the number of annual consultations:(Required)

Previous year

Current year

5b. State the number of annual procedures / surgical treatments performed:(Required)

previous year

current year

SECTION I. Additional Extended Reporting Period (AERP)

Part 3: Specific Extensions and VAPS Section

1. Do you require an Additional Extended Reporting Period of a maximum of 5 years currently offered by the Policy and subject to length of uninterrupted insurance with Genoa?(Required)

Yes

2. If YES, please confirm whether you would like a quote for the Additional Extended Reporting Period extension?(Required)

Yes

SECTION J. Hospital at Home Services

1. Do you provide Hospital at Home Services? (ask your broker for a definition)(Required)

Yes

2. If YES, please list the institutions / medical schemes that you provide Hospital at Home Services for.(Required)

SECTION K. Medical Aid Scheme and/or Third Party Administrator Forensic Audit Opposition costs

1. Do you require assistance with costs to challenge an audit by a third party payer and or a medical scheme?(Required)

Yes

2. If YES, please indicate which limit you require:(Required)

R25,000

R50,000

b. please complete the below:

i. Practice Profile

How many practitioners operate within the practice, including locums?

Does the practice use specific Practice Numbers (PNs)?

Yes

What is the location of the practice (e.g., rural vs. city)?

What is the setting for treatment—primarily rooms-based or in-hospital treatment?

Rooms-based

In-hospital

Does the practice operate from more than one hospital?

Yes

Does the practice handle a unique subset of patients (e.g., children, palliative care)?

Yes

If YES, please state

Do you submit claims to the scheme directly?

Yes

ii. Past Audit History

Have you previously been flagged for a forensic audit?

Yes

If YES, on what basis?

What was the outcome?

Have you previously signed an Acknowledgement of Debt (AOD) following a forensic audit?

Yes

Have you previously been reported to the HPCSA for incorrect billing practices?

Yes

iii. Practice Management

Are you a member of a voluntary association within your specialty?

Yes

If YES, please provide details

What method do you use for coding, billing, and collections?

Do you use Best Billing Practice tools, such as adherence to SAMA guidelines?

Yes

If your practice uses frequent billing codes that are commonly scrutinised, can you provide an explanation as to the frequent use of certain codes?

What are the practice’s procedures for record keeping regarding clinical notes, diary entries, billing, and consents?

Does your normal consent forms include provision for forensic audits?

Yes

Section L: Medico Legal Services

1. Do you provide Medico-legal services?(Required)

Yes

If YES, please confirm the percentage of time spent providing these services.

SECTION M. Telehealth Services

1. Have you in the past, or do you in the future, intend to use any of the following platforms to offer medical advice to any of your patients?

Telephone

Medici

Other

Please Specify(Required)

2. Where telehealth is being practiced would you ever offer medical advice to a patient with whom you have never previously had a physical consult?(Required)

Yes

3. Do you insist that there has been a physical consultation between the patient and yourself within at least a 12 month period prior to the telehealth/virtual consultation taking place?(Required)

Yes

4. How do you issue prescriptions following a telehealth / virtual consultation?(Required)

Telephone

Skype

Medici

Other

Please Specify(Required)

5. What is the current system you use to capture patient notes from a telehealth / virtual consultation?(Required)

Manual capture

Electronic capture

Other

Please Specify(Required)

6. Do you always bill the patient/s for the telehealth / virtual consultations?(Required)

Yes

7. Do you ensure that specific informed consent for Telehealth Services is obtained (digital signatures from patient/user is included)?(Required)

Yes

SECTION N: HIV-Protection

1. Do you require access to HIV testing and treatment in the event of a possible exposure?(Required)

Yes

SECTION O: Insurance quotation required

1. Please indicate the amount of cover you require.(Required)

Please use one of the formats below: R 1,000.00 R 100.00 R 100

SECTION P. Supporting Information Record

1. Has any medical malpractice insurer ever declined or repudiated a claim, or not paid a claim in full (other than by application of an Excess), due to your non-disclosure of material information or breach of the insurance policy?(Required)

Yes

If YES, please provide details(Required)

2. Has a medical malpractice insurer ever declined to renew your policy or requested you to seek insurance cover elsewhere?(Required)

Yes

If YES, please provide details(Required)

3. Has any medical malpractice insurer ever terminated / cancelled cover due to non-payment of the premium?(Required)

Yes

No, I have never had a successful claim against me.

If YES, please provide details

4. If you have previously had a successful malpractice claim made against you by a patient, did you put procedures in place to prevent a recurrence of the circumstances that gave rise to the claim or loss?(Required)

Yes

No, I have never had a successful claim against me.

If YES, please provide details(Required)

5a. Have you ever had any hospital privileges restricted or suspended, whether voluntarily or involuntarily?(Required)

Yes

If YES, please provide details(Required)

5b. Have you had any licence to practice and/or dispense drugs or medication revoked, suspended or limited in any way?(Required)

Yes

If YES, please provide details

5c. Have you ever had your registration with any professional body or association refused, withdrawn or made conditional?(Required)

Yes

If YES, please provide details(Required)

5d. Have you ever had conditions imposed on your practice, been suspended or removed from a medical register due to a complaint, inquiry or investigation, or been declared an “impaired physician” or fined by the HPCSA or another regulatory body?(Required)

Yes

If YES, please provide details(Required)

6. Are you currently under investigation by any hospital, other medical facility or regulatory body for any reason?(Required)

Yes

If YES, please provide details(Required)

7. Do you have formal procedures in place for dealing with patient complaints?(Required)

Yes

8. Do you ensure that all volunteers or students working at your practice are suitably qualified to provide the relevant health care services or are under the direct supervision of a suitably qualified medical practitioner at all times when providing such services?(Required)

Yes

N/A

9. Do you have procedures in place that comply with all applicable current regulations in respect of the sterilisation of instruments and the safe collection, storage and disposal of all waste including but not limited to sharps, dressings, blood products and other hazardous waste?(Required)

Yes

N/A

10. Please disclose any other information that you consider to be material in relation to the risks to be insured under this policy which have not been covered in the proposal form or this questionnaire.(Required)

SECTION Q. Addendum

Are you a:(Required)

Procedural practitioner

Non-procedural practitioner

Please choose your specialty from the list and fill in the corresponding questions.(Required)

Clinical Associates

Dentistry and Orthodontics

General Practitioners

Optometrists

Pharmacists

Clinical Associates

1. Please provide the full name and HPCSA registration number of your appointed supervising medical practitioner?

Name

HPCSA No.

2. Do you confirm that all clinical procedures performed by you are conducted under the direct supervision of the qualified health practitioner named above?

Yes

3. Do you confirm that your scope of practice remains within the prescribed regulations for Clinical Associates as defined by the HPCSA?

Yes

4. Do you maintain a written protocol or service-level agreement signed by your supervisor outlining your delegated duties?

Yes

5. Do you perform any specialised procedures (e.g., minor surgery or advanced life support) without a supervisor being physically present on the premises?

Yes

Dentistry and Orthodontics

Please indicate the breakdown of your procedures, as a percentage (%) in an average year for the following areas:

Aesthetics and Cosmetic Dentistry (%)

General Dentistry (%)

Surgical Periodontal Treatment (%)

Anaesthesia/Sedation (%)

Implantology (%)

Oral Surgery (%)

Botox or other facial cosmetics (%)

Other (please specify) (%)

Please indicate below which of the below aesthetic and cosmetic procedures you currently perform, (if any) and on average how many are performed per annum: a. Botox Injections

Y/N

No. Performed

b. Bridges

Y/N

No. Performed

c. Ceramic Fillings

Y/N

No. Performed

d. Composite Bonding

Y/N

No. Performed

e. Crowns

Y/N

No. Performed

f. Dental Implants

Y/N

No. Performed

g. Dermal Fillers

Y/N

No. Performed

h. Facial Aesthetics

Y/N

No. Performed

i. Gum Contouring

Y/N

No. Performed

j. Inlays and Onlays

Y/N

No. Performed

k. Teeth Whitening

Y/N

No. Performed

l. Veneers

Y/N

No. Performed

m. Other (please specify)

General Practitioners

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

Accident & Emergency (%)

Anaesthetics (%)

Cosmetic & Aesthetic (%)

Consultations (General) (%)

Detailed Pregnancy scans (%)

Intrapartum Obstetrics (%)

Minor Procedures performed in rooms (%)

Surgical Assistance in Theatre (%)

Procedural (incl basic scans; excl obstetrics) (%)

Telehealth Consultations (%)

Optometrists

1. Do you confirm that your current HPCSA registration category includes “Ocular Therapeutics” privileges?

Yes

2. Do you prescribe or dispense any Schedule 3 or Schedule 4 substances (e.g., ocular antibiotics, antivirals, or anti-inflammatories)?

Yes

3. Do you ensure that all prescriptions are issued in strict accordance with the approved list of pharmaceutical agents for Optometrists?

Yes

4. Do you utilise diagnostic pharmaceutical agents (e.g., cycloplegics or anaesthetic drops) in your daily practice?

Yes

5. Do you maintain a safe-keeping register for all therapeutic substances stocked or dispensed at your premises?

Yes

Pharmacists

Please indicate the category you fall into and require cover for:

Industrial Management, Group Directors, Primary Care Dispensing Therapist (PCDT), RESPONSIBLE PHARMACIST

Yes

Retail/Hospital/Industrial Pharmacist, Quality Assurance and Regulatory Affairs Pharmacist, Locum, Pharmacy/Wound care Nurse, Medical Scheme Clinical Consultant, Wholesaler/Distributor Pharmacist, Other

Yes

Pharmacy Technician

Yes

Pharmacist’s Assistant, Intern, Academic, Community Service Pharmacist)

Yes

Pharmacy Student, Pharmacy Technician Trainee and Students

Yes

1. Accident and Emergency Work

1.1 Please indicate any additional training received, including fellowships.

Institution

Year from

Year to

Name of programme/course

Certification received (e.g. ATLS)

1.2 If you have advanced life support training and certification, what date is this renewable?

2. Do you provide emergency services in a private casualty/trauma unit?

Yes

If YES, please complete the following:

Public sector position held

Year from

Year to

Please provide details of casualty/trauma unit experience in the public sector.

Please specify from which year you have been performing emergency services in the private sector.

Average number of hours per week that emergency services are provided.

3. Address of the Accident and Emergency unit/s:

4. Will there be a senior doctor present at all times?

Yes

2. Cosmetic & Aesthetic work

Please confirm which (if any) of the following procedures are performed and on average how many are performed per annum (please also add in any procedures not included in the list below):

Botox Injections

Y/N

No. Performed

Chemical peel

Y/N

No. Performed

Cosmetic tattooing

Y/N

No. Performed

Fillers

Y/N

No. Performed

Lipolytic Liposuction

Y/N

No. Performed

Microdermabrasion

Y/N

No. Performed

Permanent makeup

Y/N

No. Performed

Sclerotherapy/Smart Lipo

Y/N

No. Performed

Laser hair removal

Y/N

No. Performed

Laser wrinkle removal

Y/N

No. Performed

Threads

Y/N

No. Performed

Other (please specify)

Additional Information pertaining to Cosmetic & Aesthetic work:

2.1.All products used for the Cosmetic & Aesthetic procedures are approved by South African Health Products Regulatory Authority (SAHPRA)

Yes

2.2.Please state your relevant qualifications and experience relating to the Cosmetic & Aesthetic procedures to be performed:

Qualifications

Institution

Year achieved

2.3.1. Is it mandatory that all your patients sign consent for such procedures?

Yes

2.3.2. If NO, please provide details on how consent is taken for these procedures.

3. Surgical Assistance

1. Do you provide surgical assistance?

Yes

If YES, please complete the following: Do you assist with obstetric, neurosurgical and spinal or bariatric cases?

Yes

If YES, please specify.

Is your assistance limited to holding instruments in theatre?

Yes

If NO, please provide as much detail as possible (e.g. provide post-operative care, perform surgical closure).

How many surgeons do you assist regularly?

Past

Coming

On average, in how many procedures per annum do you act as an assistant surgeon?

Past

Coming

Do you treat children (12 years of age or younger)?

Yes

If YES, what percentage (%) of your patient base do they represent?

Past (%)

Coming (%)

Intravenous (IV) Therapy & Nutrient Infusions

Do you personally perform the IV therapy?

Yes

Do you delegate these procedures to a Registered Nurse or other qualified staff?

Yes

If delegated, do you provide direct, on-site supervision while the infusions are being administered?

Yes

Do you administer more than 20 infusions per month within the practice?

Yes

Do you typically administer infusion volumes exceeding 500ml?

Yes

Do you administer these IV drips based on a formal medical diagnosis of a clinical deficiency?

Yes

Do you administer infusions for general wellness, “hangover” recovery, or performance enhancement?

Yes

Do you conduct a full medical history and physical examination before the first infusion?

Yes

Do you require baseline blood tests (e.g., Kidney Function/U&E) prior to treatment?

Yes

Do you obtain written informed consent specifically for IV Nutrient Therapy?

Yes

Do you have a fully equipped resuscitation trolley on-site and immediately available?

Yes

Do you and your administering staff hold current certification in Basic Life Support (BLS) or ACLS?

Yes

Do you have a documented emergency protocol for the management of anaphylaxis?

Yes

Do you (and your staff) hold specific, documented training in IV Nutrient Therapy?

Yes

Important Notice

Before you enter into a contract of insurance with an Insurer, you have a duty to disclose to the Insurer every matter that you know, or could reasonably be expected to know, this is relevant to the Insurer’s decision whether to accept the risk of the insurance, and, if so, on what terms.

You have the same duty to disclose those matters to the Insurer before you renew, extend, vary or reinstate the contract of insurance.

It is important that all information contained in this proposal is understood by you and is correct, as you will be bound by your answers and by the information provided by you in this proposal. You should obtain advice before you sign this proposal if you do not properly understand any part of it.

Your duty of disclosure continues after the proposal has been completed up until the contract of insurance is entered into.

Consent(Required)

I agree to the privacy policy.

I/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 change to these facts occurring before/after 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.

Note: We recommend that you keep a record, including copies of letters and this Proposal Form, of all information supplied to us for the purpose of entering into this contract.(Required)

Signed (Add First Name & Surname)

Date

Number

Where did you hear about the Genoa Insurance offering?(Required)

Google

Social Media

Website

CPD Event

My Broker

Conference

Other

If you heard of Genoa Insurance Offering from a CPD Event, please tell us here which one:(Required)

If you heard of Genoa Insurance Offering from a conference, please tell us here which one:(Required)

If you have heard about the Genoa Insurance Offering somewhere else, please tell us where:(Required)