Medical Malpractice Insurance Proposal Form for Specialist Medical Practitioners Part 1: General SectionDisclosure* I have read and agree with the below DisclosureDisclosure: 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. 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 / Safire. 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 / Safire 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 / Safire to cease the processing of your personal information at any time and, subject to the requirements of applicable South African law, request that Genoa / Safire 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)* Part 2: Professional Indemnity And Medical Malpractice SectionSection A: Personal details of ProposerName & Surname* ID Number* Mobile Number*Work Phone*Country Of Permanent Residence* Email Website Section B: Practice DetailsPractice Address* Telephone Number*VAT Number (if applicable) HPCSA Registration Number* Practice Number (PCNS)* How long have you been practicing in total?* How long have you been practicing as a specialist?* Section C: Professional Credentials1. Please state your relevant qualifications and experience1. 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. What professional organisations or associations are you currently a member of?*4. Are you currently registered with the HPSCA as a specialist?* Yes No Please indicate your specialty and all applicable sub-specialties*SpecialitySub-speciality 5. 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 ActivityCoverage Percentage? 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:3. For all practitioners1. Do you provide chronic pain management?* Yes No If YES, please provide us with details of the chronic pain management provided.2. Do you perform Radiofrequency Ablation?* Yes No If YES, please provide a copy of your certificate of training.Max. file size: 64 MB.If YES to the question regarding Radiofrequency Ablation, please provide a list of courses attended.4. For anyone performing surgical procedures:1. Do you treat children (12 years of age or younger)? Yes No If YES to the above, do you keep minors records until they turn 21? Yes No 2. Do you perform any cosmetic procedures? Yes No 3. Do you perform laparoscopic surgery? Yes No 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 No If YES, please specify.4. Do you perform any spinal procedures? Yes No If YES, please confirm whether you perform basic spinal procedure or minimally invasive spinal surgery.Section E: Practice Management1. a) Is it mandatory that all your patients sign consent for consultations?* Yes No 1. b) Is it mandatory that all your patients sign consent for surgical procedures and/or in 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 EMGuidance None of the above Section F: Insurance History1. 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 (R): Excess (R): Previous years premium (R): Renewal date: Month Day Year Retroactive date (*only applicable if you were insured with a claims made policy in the past): Month Day Year 2. Have you ever had a break in cover where you were not insured for a period of time?* Yes No 3. 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.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:DetailsDate of claim/loss/ complaint/ incidentDate the claim/loss/complaint/ incident was madeFull details of each claim/loss/ complaint/ incidentTotal amount claimed (R)Total amount paid (R) 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 YES, please provide details:Section H: Fee Income1. Please indicate the Gross taxable turnover for the relevant periods shown below:Private practice totals:*Annual Gross Income for the previous financial year (R)Annual Gross Income estimated for the next financial year (R)Government practice totals:*Annual Gross Income for the previous financial year (R)Annual Gross Income estimated for the next financial year (R)Medico-Legal totals:*Annual Gross Income for the previous financial year (R)Annual Gross Income estimated for the next financial year (R)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:4. a) State the number of annual consultations:*Previous Year:Current Year:4. b) State the number of annual procedures / surgical treatments performed::*Previous Year:Current Year:Section I: Telehealth1. 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?* WhatsApp Email Telephone Skype Medici Other (please specify) Please specify: 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?* Yes No 3. Do you insist that there been a physical consultation between the patient and yourself within at least a 12 month period prior to telehealth / virtual consultations taking place?* Yes No 4. How do you issue prescriptions following a telehealth / virtual consultation:* WhatsApp Email Telephone Skype Medici Other (please specify) Please specify 5. What is the current system you use to capture patient notes from a telemedicine / virtual consultation?* Manual Capture Electronic Capture Other (please specify) Please specify 6. Do you always bill the patient/s for the telehealth / virtual consultations?* Yes No 7. Do you ensure that specific informed consent for Telehealth Services is obtained (digital signatures from patient/user is included)?* Yes No Section J: Hospital at Home Services1. Do you provide Hospital at Home Services? (ask your broker for a definition)* Yes No If YES, please list the institutions / medical schemes that you provide Hospital at Home Services for.Section K: Medical Aid Scheme and/or Third Party Administrator Forensic Audit Opposition Costs1. Do you require assistance with costs to challenge an audit by a third party payer and or a medical scheme?* Yes No 2. If Yes, please indicate which limit you require: R25 000 R50 000 Section L: Additional Extended Reporting Period (AERP)1. Do you require an Additional Extended Reporting Period in excess of the 60 months (5 years) currently offered by the Policy?* Yes No 2. If YES, please confirm whether you would like a quote for the Additional Extended Reporting Period extension? Yes No Section M: Medico-Legal Services1. Do you provide Medico-legal services?* Yes No If YES, please confirm the percentage of time spent providing these services.* Section N: HIV - Protection1. Do you require access to HIV testing and treatment in the event of a possible exposure?* Yes No Section O: Insurance quotation required1. Please indicate the amount of cover you require. (R)*Cover Amount (R) Section P: Supporting Information Record1. 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? Yes No If YES, please provide details2. Has a medical malpractice insurer ever declined to renew your policy or requested you to seek insurance cover elsewhere? Yes No If YES, please provide details3. 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? Yes No, I have never had a successful claim made against me. 4 a. Have you ever had any hospital privileges restricted or suspended, whether voluntarily or involuntarily? Yes No If YES, please provide details 4 b. Have you ever had any licence to practice and/or dispense drugs or medication revoked, suspended or limited in any way? Yes No If YES, please provide details 4 c. Have you ever had your registration with any professional body or association refused, withdrawn or made conditional? Yes No If YES, please provide details 4 d. 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? Yes No If YES, please provide details 5. Are you currently under investigation by any hospital, other medical facility or regulatory body for any reason? Yes No If YES, please provide details6. Do you have formal procedures in place for dealing with patient complaints? Yes No 7. 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? Yes No N/A 8. 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? Yes No N/A 9. 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.Section Q: AddendumView Addendum* Yes No Obstetrics/Gynaecology/MaternityDo you undertake obstetrics procedures? Yes No Please provide details of the number of the following procedures (if any) done per annum in the following categories: (If you did not perform a procedure, please type "0" in the field)Number of vaginal deliveries conducted:Previous Financial YearCurrent Financial YearNumber caesarean deliveries conducted:Previous Financial YearCurrent Financial YearNumber of vaginal delivieries conducted for patients who previously had a caesarean:Previous Financial YearCurrent Financial YearNumber of pregnancy ultrasounds conducted:Previous Financial YearCurrent Financial YearNumber of laparoscopic surgeries conducted:Previous Financial YearCurrent Financial YearNumber of vaginal surgeries conducted (including hysterectomies):Previous Financial YearCurrent Financial YearNumber of open surgeries:Previous Financial YearCurrent Financial YearPlease provide us with the breakdown of births done below:Average Number Of Deliveries Per YearSingle BirthsMultiple BirthsStillbornsHave you done any post-graduate training and/or have specialist qualification for the following procedures and, if so, please provide details:Pregnancy Ultrasounds Yes No If YES, please provide details: Laparoscopic surgery Yes No 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 No Ensure continuous electronic foetal monitoring performed on all patients in active labour? Yes No Personally approve the ordering, and supervise the use, of oxytoxic drugs? Yes No Ensure that an obstetrician is available for patients 24 hours per day? Yes No Ensure that you are able to perform a caesarean section within 30 minutes, 24 hours a day? Yes No Regularly perform deliveries outside of the hospital? Yes No Follow the SASOG BetterObs Programme and SASOG protocols? Yes No Ophthalmologists:1. Does your practice perform eye care of premature infants at risk of/with established ROP? Yes No 2. Do you perform any Laser refractive surgery? Yes No If YES, How many of these procedures do you perform per annum? 3. Do you perform oculoplastic procedures for cosmetic rather than functional reasons? Yes No 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 Yes No Number Performed:b. Chemical peel Yes No Number Performed:c. Cosmetic Tattooing Yes No Number Performed:d. Fillers Yes No Number Performed:e. Laser hair removal Yes No Number Performed:f. Laser wrinkle removal Yes No Number Performed:g. Microdermabrasion Yes No Number Performed:h. Permanent makeup Yes No Number Performed:i. Sclerotherapy/ Smart Yes No Number Performed:j. Lipo Threads Yes No Number Performed:k. Breast Enhancement: Augmentation, Lift, Reduction Yes No Number Performed:l. Facial Contouring: Rhinoplasty, Chin, or Cheek Enhancement Yes No Number Performed:m. Facial Rejuvenation: Facelift, Eyelid Lift, Neck Lift, Brow Lift Yes No Number Performed:n. Body Contouring: Tummy Tuck, Lipolytic Liposuction Yes No Number Performed:Paediatricians1 a. Do you treat infants after the first 7 days of life? Yes No 1 b. Do you treat infants in the first 7 days of life exclusively in an office-based or outpatient setting? Yes No 1 c. Do you treat infants in the first 28 days of life? Yes No 2. Do you attend to deliveries? Yes No 3. Do you look after neonates in the ICU? Yes No 4. Does the Neonatal ICU centre at which you attend, have advanced technology to provide specialised treatment? Yes No SurgeryPlease indicate the breakdown of your surgical procedures in an average year as follows:1 a. In-theatre surgical procedures: How many procedures do you perform on average per annum as primary surgeon?Past yearComing year 1 b. How many procedures per annum do you act as an assistant surgeon?Past yearComing year 2 a. If you only provide surgical assistance (as opposed to acting as the primary surgeon), please complete the following:Past yearComing year 2 b. Is your assistance limited to holding instruments in theatre to support the primary surgeon? Yes No 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. Please list your most commonly performed procedures per annum.Procedure or ICD codeRisk level of Procedure (Minor, Moderate or Major)No. performed% of procedures performed in Private Practice% of procedures performed in State Additional documentation required for Obstetrics & Gynaecology / Neurosurgery / Spinal Surgery or Plastic & Cosmetic SurgeryA detailed summary of your claims history (This can be obtained directly from your current indemnity provider)Accepted file types: jpg, png, pdf, Max. file size: 5 MB.A detailed copy of your CVAccepted file types: jpg, png, pdf, Max. file size: 2 MB.Copies of your certificates of additional training Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 2 MB, Max. files: 5. Any supplementary information you wish to provide that would assist with the underwriting process?DeclarationImportant 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. 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 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 accept* Yes Date* Day Month Year NameThis field is for validation purposes and should be left unchanged.