Medical Malpractice Insurance Proposal Form for Specialist Medical Practitioners ARE YOU A GP, DENTIST OR GENERAL MEDICAL PRACTITIONER? CLICK BELOW TO COMPLETE THIS FORM GET THE COVER YOU NEED Specialist Medical Practitioners Part 1: General SectionDisclosure: 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. Part 2: Medical Malpractice SectionSection A: Personal details of ProposerName & Surname*ID Number*Country Of Permanent Residence*Mobile Number*Work Phone*Email Website Section B: Practice DetailsTelephone Number*Practice Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country VAT Number (if applicable)*HPCSA Registration Number*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 activitiesListProfessional 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?*YesNoIf YES, please provide us with details of the chronic pain management provided.2. Do you perform Radiofrequency Ablation?*YesNoIf YES, please provide a copy of your certificate of training.4. For anyone performing surgical procedures:1. Do you treat children (12 years of age or younger)?YesNoIf YES to the above, do you keep minors records until they turn 21?YesNo2. Do you perform any cosmetic procedures?YesNo3. Do you perform laparoscopic surgery?YesNoIf 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)?YesNoIf YES, please specify.4. Do you perform any spinal procedures?YesNoIf 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?*YesNo1. b) Is it mandatory that all your patients sign consent for surgical procedures and/or in theatre treatment?*YesNo2. What is the current system you use to capture patient notes?*Manual CaptureDigital Capture3. How are your patient records secured?*Hard CopyElectronic Format4. How long do you retain patients' medical records?*5. Which of the following do you use for your internal risk management?*HealthspaceMedawareMedscapeUp to DateWordsureSection F: Insurance History1. Have you ever had a break in cover where you were not insured for a period of time?* Yes No 2. Have you had any break in clinical practice over the past 5 years?*YesNoIf you answered YES to any of the above, then please give details.3. Are you currently or have been in the past insured for the type of insurance now being proposed*YesNoIf YES, then please confirm:Current Insurers:Limit of Indemnity:Excess:Previous years premium:Renewal date:Retroactive date (*only applicable if you were insured with a claims made policy in the past):Section G: Claims Experience1. Are you aware of any circumstances which might give rise to a claim against you which has not already been initiated?YesNoIf YES, please provide details:2. Has any formal written complaint been made against you with any regulatory body, including the HPCSA, in your capacity as a medical practitioner?*YesNo3. Has any disciplinary enquiry been initiated against you with any regulatory body, including the HPCSA, in your capacity as a medical practitioner?*YesNo4. Has any monetary claim been made against you arising out of your professional conduct as a medical practitioner?*YesNoIf you answered YES to any of the questions above, please give details below:If you answered YES to any of the questions above, please give details below:Date of claim/loss/ complaint/ incidentDate the claim/loss/complaint/ incident was madeFull details of each claim/loss/ complaint/ incidentTotal amount claimedTotal amount paid Section H: Fee Income1. Please indicate the Gross taxable turnover for the relevant periods shown below:Private practice totals:*Annual Gross Income for the current financial yearAnnual Gross Income estimated for the next financial yearGovernment practice totals:*Annual Gross Income for the current financial yearAnnual Gross Income estimated for the next financial year2. 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: Insurance quotation required1. Please indicate the amount of cover you require (R)?*2. Please indicate whether you currently pay your premium by way of:* A monthly debit order comprising of 10 equal instalments A monthly debit order comprising of 12 equal instalments A once off debit order comprising of a single installment A once off EFT comprising of a single installment AddendumOnly applicable to the following disciplines: Obstetricians, Gynaecologists, General Surgeons, Ophthalmologist, Plastic And Reconstructive Surgeons and Paediatricians.View Addendum* Yes No Obstetrics/Gynaecology/MaternityDo you undertake obstetrics procedures?YesNoPlease 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 of vaginal delivieries conducted for patients who previously had a caesarean:Previous Financial YearCurrent Financial YearNumber caesarean deliveries conducted: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 UltrasoundsYesNoIf YES, please provide details:Laparoscopic surgeryLaparoscopic surgery:YesNoIf 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:YesNoEnsure continuous electronic foetal monitoring performed on all patients in active labour?YesNoPersonally approve the ordering, and supervise the use, of oxytoxic drugs?YesNoEnsure that an obstetrician is available for patients 24 hours per day?YesNoEnsure that you are able to perform a caesarean section within 30 minutes, 24 hours a day?YesNoRegularly perform deliveries outside of the hospital?YesNoFollow the SASOG BetterObs Programme and SASOG protocols?YesNoOphthalmologists:1. Does your practice provide screening for or treatment of retinopathy of prematurity? Yes No 2. Do you perform any Laser refractive surgery? 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 InjectionsYesNoNumber Performed:b. Chemical peelYesNoNumber Performed:c. Cosmetic TattooingYesNoNumber Performed:d. FillersYesNoNumber Performed:e. Laser hair removalYesNoNumber Performed:f. Laser wrinkle removalYesNoNumber Performed:g. MicrodermabrasionYesNoNumber Performed:h. Permanent makeupYesNoNumber Performed:i. Sclerotherapy/ SmartYesNoNumber Performed:j. Lipo ThreadsYesNoNumber Performed:k. Breast Enhancement: Augmentation, Lift, ReductionYesNoNumber Performed:l. Facial Contouring: Rhinoplasty, Chin, or Cheek EnhancementYesNoNumber Performed:m. Facial Rejuvenation: Facelift, Eyelid Lift, Neck Lift, Brow LiftYesNoNumber Performed:n. Body Contouring: Tummy Tuck, Lipolytic LiposuctionYesNoNumber Performed:Paediatricians1. 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:BariatricSplit %CardiacSplit %Elective CosmeticSplit %Elective Termination of PregnancySplit %OrthopaedicSplit %Gender ReassignmentSplit %Surgery (Intermediate)Split %OtherSplit %Please specify: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.A detailed copy of your CVAccepted file types: jpg, png, pdf.Copies of your certificates of additional training Drop files here or Accepted file types: jpg, png, pdf. Any supplementary information you wish to provide that would assist with the underwriting process?DeclarationI/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* MM DD YYYY
