MC De Villiers Specialist Form - Genoa Underwriting Managers

Medical Malpractice Insurance Proposal Form for Specialist Medical Practitioners

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Part 1 General Section

Disclosure

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. 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.

You acknowledge that the personal information you supply is provided voluntarily and therefore constitutes specific, voluntary consent to the processing of such information by Genoa / Lombard. Your personal information will be processed for:

General and specific underwriting and risk assessment purposes;

Statistical research and / or reporting;
the legitimate interests of Genoa / Lombard and / or yourself; and

any statutory or regulatory compliance (where applicable).

You have the right to request access to, and correction of, your personal information. You can instruct Genoa / Lombard to cease the processing of your personal information at any time and, subject to the requirements of applicable South African law, request that Genoa / Lombard delete and/or de-identify such personal information.

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, re-insurers, 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, and to allow the Insurer/ Underwriting Management Agency to correctly allocate premium payments.

We assure you that when the Insurer/Underwriting Management Agency share your personal information with selected service providers/ third parties, for the specific purposes outlined herein, that we will ensure that the appropriate protections of your personal information are in place in accordance with our obligations under the 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.

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.

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 including province(Required)

2. Telephone number(Required)

3. VAT number (if applicable)

4. HPCSA registration number(Required)

5. Practice Number (PCNS)(Required)

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

7. How long have you been practicing as a specialist?(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. What professional organisations or associations are you currently a member of?(Required)

4. Are you currently registered with the HPCSA as a specialist?(Required)

Yes

Please indicate your specialty and all applicable sub-specialties(Required)

Neurosurgery

Obstetrics/Gynaecology/Maternity

Opthalmologists

Orthopaedic Surgery

Otorhinolaryngology (ENT)

Plastic and Reconstructive Surgery

Paediatricians

Radiology

Surgery

5. 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

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

Yes

If YES to the above, do you keep minors records until they turn 21?

Yes

2. Do you perform any cosmetic procedures?

Yes

3. Do you perform laparoscopic or arthroscopic surgery?

Yes

If YES to the above, how many of these procedures do you perform per annum?

a. Have you received any additional training in this field (e.g. medical residence or fellowship programs)?

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

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

Please upload any necessary files to support your claims experience.

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)

Upload your file here(Required)

Max. file size: 64 MB.

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 your files here(Required)

Max. file size: 64 MB.

1a. 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

1b. 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

1c. 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

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

State Hospitals (%)

Private Practice (%)

The total amount between both State and Private must equal 100%

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

State Hospitals

Private Practice

4a. State the number of annual consultations:(Required)

Previous year

Current year

4b. 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

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

R25,000

R50,000

b. please also answer the below sections i. ii. and ii.

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. 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 M. 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 N: Insurance Quotation Required

1. Please indicate the amount of cover you require.

Please use one of the following format examples: R 1,000.00 R 100.00 R 100

SECTION O. 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

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.

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 P. Addendum

Please complete the below questions only relating to your specific specialist practice:

Please choose your specialty and fill in the corresponding fields

Neurosurgery

Obstetrics/Gynaecology/Maternity

Opthalmologists

Orthopaedic Surgery

Otorhinolaryngology (ENT)

Plastic and Reconstructive Surgery

Paediatricians

Radiology

Surgery

Neurosurgery

1. In terms of the number of surgical procedures you perform as primary surgeon, please indicate percentages for the following:

Cranial procedures: Past Year

Cranial procedures: Coming Year

Spinal procedures: Past Year

Spinal procedures: Coming Year

2a. What percentage of patients under your care suffer from acute trauma-related injuries?

2b. What percentage of these relate to spinal trauma?

3. Do you perform corrective procedures for disorders of spinal curvature?

Yes

If YES, please specify type of procedures:

4. How many shunt-related surgeries do you perform on average per annum?

Adults: Past Year

Paediatrics: Coming Year

Adults: Past Year

Adults: Coming Year

Obstetrics/Gynaecology/Maternity

Do you undertake obstetrics procedures?

Yes

Please provide details of the number of vaginal deliveries conducted (if any) per annum in the following categories:

Previous financial year

Current financial year

Please provide details of the number of caesarean deliveries conducted (if any) per annum in the following categories:

Previous financial year

Current financial year

Please provide details of the number of vaginal deliveries conducted for patients who previously had a caesarean (if any) per annum in the following categories:

Previous financial year

Current financial year

Please provide details of the number of pregnancy ultrasounds conducted (if any) per annum in the following categories:

Previous financial year

Current financial year

Please provide details of the number of laparoscopic surgeries conducted (if any) per annum in the following categories:

Previous financial year

Current financial year

Please provide details of the number of vaginal surgeries conducted (including hysterectomies) (if any) per annum in the following categories:

Previous financial year

Current financial year

Please provide details of the number of open surgeries (if any) per annum in the following categories:

Previous financial year

Current financial year

Please provide us with the breakdown of the average number of single birth deliveries per year

Please provide us with the breakdown of the average number of multiple births deliveries per year

Please provide us with the breakdown of the average number of stillborn deliveries per year

Have you done any post-graduate training and/or have specialist qualification for pregnancy ultrasounds and, if so, please provide details:

Yes

If YES, please provide details

Have you done any post-graduate training and/or have specialist qualification for the following procedures and, if so, please provide details: Pregnancy ultrasounds

Yes

If YES, please provide details

Have you done any post-graduate training and/or have specialist qualification for the following procedures and, if so, please provide details: Laparoscopic surgery

Yes

If YES, please provide details

Do you (or a suitably qualified locum who you appoint in the event that you are unavailable) ensure ongoing foetal monitoring readings periodically during labour or delivery?

Yes

Do you (or a suitably qualified locum who you appoint in the event that you are unavailable) ensure continuous electronic foetal monitoring performed on all patients in active labour?

Yes

Do you (or a suitably qualified locum who you appoint in the event that you are unavailable) personally approve the ordering, and supervise the use, of oxytoxic drugs?

Yes

Do you (or a suitably qualified locum who you appoint in the event that you are unavailable) ensure that an obstetrician is available for patients 24 hours per day?

Yes

Do you (or a suitably qualified locum who you appoint in the event that you are unavailable) ensure that you are able to perform a caesarean section within 30 minutes, 24 hours a day?

Yes

Do you (or a suitably qualified locum who you appoint in the event that you are unavailable) regularly perform deliveries outside of the hospital?

Yes

Do you (or a suitably qualified locum who you appoint in the event that you are unavailable) regularly perform deliveries outside of the hospital?

Yes

Do you (or a suitably qualified locum who you appoint in the event that you are unavailable) follow the SASOG BetterObs Programme and SASOG protocols?

Yes

Ophthalmologists

1. Does your practice perform eye care of premature infants at risk of/with established ROP?

Yes

If YES, do you perform anti-VEGF injections or laser photocoagulation for ROP?

Yes

2. Do you perform any Laser Refractive Surgery (e.g., LASIK, PRK, SMILE)?

Yes

If YES, How many of these procedures do you perform per annum?

3. Do you perform Keratoconus management involving Corneal Cross-linking (CXL)?

Yes

4. Do you perform Corneal Transplants (Grafts)?

Yes

5. Do you perform oculoplastic procedures for cosmetic rather than functional reasons (e.g., aesthetic blepharoplasty)?

Yes

6. Do you administer Botulinum Toxin or Dermal Fillers for non-therapeutic purposes?

Yes

7. Do you perform cataract Surgery

Yes

If YES, how many cataract extractions do you perform per annum?

8. Do you perform Minimally Invasive Glaucoma Surgery (MIGS) or traditional trabeculectomies?

Yes

9. Do you perform surgery in high-volume “Cataract Camp” settings or mobile surgical units?

Yes

10. Do you perform Vitreoretinal (VR) surgery (e.g., for retinal detachments or diabetic retinopathy)?

Yes

11. Do you perform intravitreal injections in a rooms-based setting?

Yes

If YES, please confirm if a sterile “clean room” protocol is strictly followed:

Yes

12. Do you perform surgery for Strabismus (squints) in children?

Yes

13. Do you perform paediatric cataract surgery?

Yes

Orthopaedic Surgery

1. Please indicate the percentage of your total surgical output for the following categories:

General Orthopaedics / Trauma: Past year

General Orthopaedics / Trauma: Coming year

Arthroplasty (Hips & Knees): Past year

Arthroplasty (Hips & Knees): Coming year

Spinal Surgery: Past year

Spinal Surgery: Coming year

Hand / Upper Limb Surgery: Past year

Hand / Upper Limb Surgery: Coming year

Paediatric Orthopaedics: Past year

Paediatric Orthopaedics: Coming year

2a. Spinal Surgery (To be completed only if Spinal Surgery is performed): Indicate the distribution of your spinal work: Cervical

2b. Spinal Surgery (To be completed only if Spinal Surgery is performed): Indicate the distribution of your spinal work: Thoracic

2c. Spinal Surgery (To be completed only if Spinal Surgery is performed): Indicate the distribution of your spinal work: Lumbar

Do you perform Corrective surgery for Scoliosis/Kyphosis:

Yes

Do you perform Spinal Cord Tumour Resection:

Yes

Do you perform Revision Spinal Surgery (Multi-level):

Yes

Do you perform Disc Replacements (Cervical or Lumbar):

Yes

3a. What percentage of your practice involves acute trauma (fractures/dislocations)?

3b. What percentage of your trauma cases involve spinal cord or vertebral column injuries?

3c. Do you provide on-call services for Level 1 or Level 2 Trauma Centres?

Yes

4a. How many primary joint replacements do you perform per annum?

4b. How many revisions joint replacements do you perform per annum?

4c. Do you utilize robotic-assisted surgery or computer-aided navigation?

Yes

5a. Do you utilize Intraoperative Neuromonitoring (IONM) for all instrumentation cases?

Yes

5b. Do you maintain a personal registry of outcomes or participate in a national registry (e.g., SAOA)?

Yes

5c. Are patients routinely screened for MRSA/infection risks prior to elective spinal/joint surgery?

Yes

Otorhinolaryngology (ENT)

Do you perform paediatric airway surgery (e.g., laryngoscopy, bronchoscopy, or tracheostomy)?

Yes

How many paediatric tonsillectomies/adenoidectomies do you perform per annum?

Do you perform Cochlear Implant surgery?

Yes

Do you perform major head and neck resections for malignancy?

Yes

Do you perform Thyroid and/or Parathyroid surgery?

Yes

If YES, do you routinely use intraoperative nerve monitoring for the recurrent laryngeal nerve?

Yes

Do you perform Parotid or Submandibular gland surgery?

Yes

Do you perform Functional Endoscopic Sinus Surgery (FESS)?

Yes

Do you perform advanced endoscopic skull base surgery (e.g., CSF leak repairs, pituitary tumor resection)?

Yes

Please indicate if you perform the following:

Rhinoplasty

Functional/Septoplasty only

Cosmetic/Aesthetic Rhinoplasty

Revision Rhinoplasty

Otoplasty (Correction of prominent ears)

Facial Aesthetic Surgery

Blepharoplasty (Eyelid surgery)

Rhytidectomy (Face/Neck lift)

Mentoplasty (Chin augmentation)

Do you perform any of the aesthetic procedures listed above in a rooms-based “procedure room” rather than a formal theatre?

Yes

If YES, please specify which procedures:

Do you utilise Image-Guided Surgery (Navigation) for complex sinus or skull base cases?

First Choice

Second Choice

Third Choice

Plastic and Reconstructive Surgeons

1. In terms of the number of patients you treat, what percentage of your patients are anticipated to have predominantly cosmetic as opposed to reconstructive procedures?

2. If cosmetic procedures are performed, please confirm which (if any) of the following procedures are performed and on average how many are performed per annum: a. Botox Injections

Y/N

No. Performed

b. Chemical peel

Y/N

No. Performed

c. Cosmetic Tattooing

Y/N

No. Performed

d. Fillers

Y/N

No. Performed

e. Laser hair removal

Y/N

No. Performed

f. Laser wrinkle removal

Y/N

No. Performed

g. Microdermabrasion

Y/N

No. Performed

h. Permanent Makeup

Y/N

No. Performed

i. Sclerotherapy/ Smart

Y/N

No. Performed

j. Lipo Threads

Y/N

No. Performed

k. Breast Enhancement: Augmentation, Lift, Reduction

Y/N

No. Performed

l. Facial Contouring: Rhinoplasty, Chin or Cheek Enhancement

Y/N

No. Performed

m. Facial Rejuvenation: Facelift, Eyelid Lift, Neck Lift, Brow Lift

Y/N

No. Performed

n. Body Contouring: Tummy Tuck, Lipolytic Liposuction

Y/N

No. Performed

Paediatricians

1a. Do you treat infants after the first 7 days of life; or

Yes

1b. in the first 7 days of life exclusively in an office-based or outpatient setting; or; or

Yes

1c. in the first 28 days of life?

Yes

2. Do you attend to deliveries?

Yes

3. Do you look after neonates in the ICU?

Yes

4. Does the Neonatal ICU centre at which you attend, have advanced technology to provide specialised treatment?

Yes

Radiology

1. Do you perform fetal sonars after 12 weeks of gestation?

Yes

2. Do you report on detailed pregnancy scans including nuchal translucency scans that are aimed at detecting fetal anomalies?

Yes

3. Do you perform interventional procedures?

Yes

If YES, please specify the types of procedures performed:

Surgery

1a. In-theatre surgical procedures, how many procedures do you perform on average per annum as primary surgeon?

Past year

Coming year

1b. In-theatre surgical procedures, how many procedures per annum do you act as an assistant surgeon?

Past year

Coming year

2a. If you only provide surgical assistance (as opposed to acting as the primary surgeon), how many surgeons do you assist regularly?

Past year

Coming year

2b. Is your assistance limited to holding instruments in theatre to support the primary surgeon?

Yes

If NO, please provide as much detail as possible (e.g. position the patient and start surgery to prepare operative field, perform surgical closure, provide post-operative care, teach/supervise a particular skill):

3. Do you perform bariatric surgery?

Yes

3a. Are you certified by a professional body to perform bariatric surgery?

Yes

If YES, by which organisation?

3b. Do you perform bariatric surgery in the context of a multidisciplinary team?

Yes

If YES, please provide details:

3c. How many of these procedures do you perform per annum as primary surgeon?

Past Year

Coming Year

4. Do you perform robotic-assisted surgery?

Yes

If YES, how many procedures do you perform per annum as the primary surgeon?

Past Year

Coming Year (Forecast)

Please specify any additional formal training or fellowships completed in robotic surgery:

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.

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