Specialist Medical Practitioners Form

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 uploaded with this form.

I/We the undersigned duly authorised person(s) declare that:

1. I am/we are authorised by each of the Insureds to sign this Proposal Form.
2. The above statements are correct, true and complete.
3. No information material to this Proposal Form has been withheld.
4. 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.
5. I/we have diligently made all necessary and detailed enquiries in order to comply with the duty of disclosure.
6. 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.
7. 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.
8. I/we understand that no insurance is in force until such time as the Insurer has confirmed acceptance of the proposed insurance.
9. I/we undertake to inform the Insurer of any material alteration to these facts occurring before completion of the contract of insurance.
10. 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.
11. 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.
12. 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.