Supporting Information Record - Genoa Underwriting Managers

Medical Malpractice Insurance Supporting Information Record For Healthcare Professionals

Please be advised that this proposal form is underwritten on a claims made basis.

The policy would not provide cover for:
- Events that occurred prior to the retroactive date
- Claims made after the expiry of the policy period even though the wrongful act giving rise to the claim may have occurred during the policy period
- Claims notified or arising out of facts or circumstances notified under any previous policy or noted on the current proposal form or any previous proposal form
- Claims made, threatened or intimated prior to the commencement of the policy period
- Facts or circumstances in your knowledge prior to the policy period, which you knew had the potential to give rise to a claim under this policy.
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. Have you ever had:
Any hospital privileges restricted or suspended, whether voluntarily or involuntarily?*
- Yes
- No
If YES, please provide details:
Any licence to practice and/or dispense drugs or medication revoked, suspended or limited in any way?*
- Yes
- No
If YES, please provide details:
Your registration with any professional body or association refused, withdrawn or made conditional?*
- Yes
- No
If YES, please provide details:
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
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
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.*
Declaration

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 agree*
- Yes
Date*
Month
Day
Year

Medical Malpractice Insurance Supporting Information Record For Healthcare Professionals

4. Have you ever had:

Declaration

Medical Professionals
State Healthcare Practitioners
Legal Practitioners
Business Rescue Practitioners
Executors, Curators & Trustees
Financial Service Providers
Liquidators

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