Medical Malpractice Insurance Proposal Form for Specialist Medical Practitioners

ARE YOU A GP, DENTIST OR GENERAL MEDICAL PRACTITIONER? CLICK BELOW TO COMPLETE THIS FORM

Specialist Medical Practitioners

Part 1: General Section
Disclosure*
I have read and agree with the below Disclosure
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.
- 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:
1. General and specific underwriting and risk assessment purposes;
2. Statistical research and / or reporting;
  the legitimate interests of Genoa / Safire and / or yourself; and
3. 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 Section
Section A: Personal details of Proposer
Name & Surname*
ID Number*
Mobile Number*
Work Phone*
Country Of Permanent Residence*
Email
Website
Section B: Practice Details
Practice 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 Credentials
1. Please state your relevant qualifications and experience
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. 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*
Speciality Sub-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 activities
1. Please confirm the percentage breakdown of the professional activities offered by you and for which you require cover:
Professional Activity Coverage 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 practitioners
1. 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 Management
1. 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 History
1. 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 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:
Details
Date of claim/loss/ complaint/ incident Date the claim/loss/complaint/ incident was made Full details of each claim/loss/ complaint/ incident Total 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 Income
1. 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: Telehealth
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?*
- 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 Services
1. 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 Costs
1. 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 Services
1. Do you provide Medico-legal services?*
- Yes
- No
If YES, please confirm the percentage of time spent providing these services.*
Section N: HIV - Protection
1. Do you require access to HIV testing and treatment in the event of a possible exposure?*
- Yes
- No
Section O: Insurance quotation required
1. Please indicate the amount of cover you require. (R)*
Cover Amount (R)
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?
- Yes
- No
If YES, please provide details
2. 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 details
3. 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 details
6. 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: Addendum
View Addendum*
- Yes
- No
Obstetrics/Gynaecology/Maternity
Do 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 Year Current Financial Year
Number caesarean deliveries conducted:
Previous Financial Year Current Financial Year
Number of vaginal delivieries conducted for patients who previously had a caesarean:
Previous Financial Year Current Financial Year
Number of pregnancy ultrasounds conducted:
Previous Financial Year Current Financial Year
Number of laparoscopic surgeries conducted:
Previous Financial Year Current Financial Year
Number of vaginal surgeries conducted (including hysterectomies):
Previous Financial Year Current Financial Year
Number of open surgeries:
Previous Financial Year Current Financial Year
Please provide us with the breakdown of births done below:
Average Number Of Deliveries Per Year
Single Births Multiple Births Stillborns
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
- 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:
Paediatricians
1 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
Surgery
Please 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 year Coming year
1 b. How many procedures per annum do you act as an assistant surgeon?
Past year Coming year
2 a. If you only provide surgical assistance (as opposed to acting as the primary surgeon), please complete the following:
Past year Coming 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 code Risk 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 Surgery
A 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 CV
Accepted file types: jpg, png, pdf, Max. file size: 2 MB.
Copies of your certificates of additional training
Drop files here or

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?
Declaration
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.

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.
I accept*
- Yes
Date*

Day
Month
Year
Phone
This field is for validation purposes and should be left unchanged.

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.

Medical Malpractice Insurance Proposal Form for Specialist Medical Practitioners

ARE YOU A GP, DENTIST OR GENERAL MEDICAL PRACTITIONER? CLICK BELOW TO COMPLETE THIS FORM

Specialist Medical Practitioners

Part 1: General Section

Part 2: Professional Indemnity And Medical Malpractice Section

Section A: Personal details of Proposer

Section B: Practice Details

Section C: Professional Credentials

1. Please state your relevant qualifications and experience

Section D: Insured's professional activities

3. For all practitioners

4. For anyone performing surgical procedures:

Section E: Practice Management

Section F: Insurance History

If YES, then please confirm:

Section G: Claims Experience

If you answered YES to any of the questions above, please give details below:

Section H: Fee Income

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

Section I: Telehealth

Section J: Hospital at Home Services

Section K: Medical Aid Scheme and/or Third Party Administrator Forensic Audit Opposition Costs

Section L: Additional Extended Reporting Period (AERP)

Section M: Medico-Legal Services

Section N: HIV - Protection

Section O: Insurance quotation required

Section P: Supporting Information Record

Section Q: Addendum

Obstetrics/Gynaecology/Maternity

Ophthalmologists:

Plastic and Reconstructive Surgeons:

Paediatricians

Surgery

Additional documentation required for Obstetrics & Gynaecology / Neurosurgery / Spinal Surgery or Plastic & Cosmetic Surgery

Declaration

Important Notice

Built Environment
Educational Environment
Fiduciary Environment
Financial Environment
Legal Environment
Medical Environment
Miscellaneous Environment
Restructuring Environment

Genoa Is An Authorised Financial Services Provider. FSP 38225, Underwritten By Safire Insurance Company FSP 2092

Qualification(s)	Institution	Year Achieved

Speciality	Sub-speciality

Professional Activity	Coverage Percentage?

Date of claim/loss/ complaint/ incident	Date the claim/loss/complaint/ incident was made	Full details of each claim/loss/ complaint/ incident	Total amount claimed (R)	Total amount paid (R)

Medical Malpractice Insurance Proposal Form for Specialist Medical Practitioners

ARE YOU A GP, DENTIST OR GENERAL MEDICAL PRACTITIONER? CLICK BELOW TO COMPLETE THIS FORM

Specialist Medical Practitioners

Part 1: General Section

Disclosure: medical practitioners / healthcare professionals

Privacy and Sharing of Information

Part 2: Professional Indemnity And Medical Malpractice Section

Section A: Personal details of Proposer

Section B: Practice Details

Section C: Professional Credentials

1. Please state your relevant qualifications and experience

Section D: Insured's professional activities

3. For all practitioners

4. For anyone performing surgical procedures:

Section E: Practice Management

Section F: Insurance History

If YES, then please confirm:

Section G: Claims Experience

If you answered YES to any of the questions above, please give details below:

Section H: Fee Income

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

Section I: Telehealth

Section J: Hospital at Home Services

Section K: Medical Aid Scheme and/or Third Party Administrator Forensic Audit Opposition Costs

Section L: Additional Extended Reporting Period (AERP)

Section M: Medico-Legal Services

Section N: HIV - Protection

Section O: Insurance quotation required

Section P: Supporting Information Record

Section Q: Addendum

Obstetrics/Gynaecology/Maternity

Ophthalmologists:

Plastic and Reconstructive Surgeons:

Paediatricians

Surgery

Additional documentation required for Obstetrics & Gynaecology / Neurosurgery / Spinal Surgery or Plastic & Cosmetic Surgery

Declaration

Important Notice