Individual Practitioners Private Practice


Thank you for your interest in an insurance policy arranged through Premium Medical Protection. Please carefully read the following information before proceeding with your application.

Premium Medical Protection only arranges cover for the specialties listed under question 1 of the Activities section of the application form. Please only proceed with an application if your specialty is listed. If your specialty is not listed we are unable to arrange cover and you should not continue with the application. Premium Medical Protection does not arrange cover for Obstetrics, General Practitioners and Paramedics amongst others.

Please note you will be required to provide a confirmed claims experience covering your private practice for the past 10 years.

1. Disclosure

You must provide complete and accurate answers to the questions we ask you when you purchase a policy for the first time, make changes to your policy, or renew your policy.

Insurance is based on the information that you give to the insurer and if this information is wrong or incomplete, there may be adverse consequences: claims may not be paid in full or at all, your policy may have special terms imposed or be cancelled, your policy may be voided, and the premium paid may not be returned. If you are in doubt, please seek independent advice or contact us for clarification.

You must provide us with a “fair presentation” of the risk. This is one:

  1. which discloses every “material circumstance” which you know, or ought to know, or which puts the insurers on notice that it needs to make further enquiries for the purpose of revealing those material circumstances, and
  2. in which every material representation as to a matter of fact is substantially correct, and every material representation as to a matter of expectation or belief is made in good faith.

A “material circumstance” is one which would influence the judgment of a “prudent insurer” in fixing the premium or determining whether to cover the risk.

You must make this disclosure in a manner which would be reasonably clear and accessible to a “prudent insurer”.

Additionally, once the policy has come into effect, the policy itself contains specific terms requiring you to notify us in a timely fashion regarding incidents and circumstances that are reasonably likely to result in a claim being made against you.

This application form must be completed by the proposed individual. All questions must be answered. If there is insufficient space to provide answers, additional information should be provided on the proposers’ letter-headed paper.

2. Formalities

Premium Medical Protection is an appointed representative of Harley Street Insurance Group Limited, which is authorised and regulated by the Financial Conduct Authority (FRN: 570717).

This is a legally binding document and requires a signature from the applicant. A copy of the application that you have completed online will be emailed to you for signature. On receipt, please sign and return by Fax to 0207 806 0810 or by post to Premium Medical Protection, 25 Athena Court, Athena Drive, Tachbrook Park, Warwick, CV34 6RT. The insurer requires a signed copy of the application for any policy of insurance to become valid.

3. Provision of Run-Off Cover – Claims Made Policies

Please note that additional terms apply in respect of run-off cover. If you are likely to retire from private practice in the next 36 months please contact us to discuss your options prior to making an application.

4. Your Data

We will only use your information insofar as it is necessary to administer your insurance contract or in connection with a claim. Please see our Privacy Notice for more information on how we handle your data.

Contact Details

The details given will be used to make contact with you. All queries and documentation relating to your application/policy will be sent to the email address provided and this includes a copy of your application form containing your personal information.

If different from your username.

(I) Please note that correspondence relating to your application/policy may be sent to the address provided.

Please ensure that the email address provided is secure and can only be accessed by you.

An online client account will also be created and copies of all documentation can also be accessed here. The email address provided will serve as your username.

Section A – Personal Details

Section B – Academic & Professional Details



Section C – Indemnity

Previous Insurer Start Date End Date Limit of Indemnity Excess


Section D – Activities

If none, please enter a zero.

If entering private practice for the first time or did not have private practice income in the previous year, please provide estimates of your income in each of these categories for the next year.


Income figures below should equal, this, the Total Gross Annual Income from Private Practice


Consultation Income should not include income derived from any medical procedure or surgery, nor any follow up care related to that procedure or surgery.


Please include any surgical income here, you must give any additional information regarding where this income is derived from in the text box below. e.g Surgical or Procedures

Section E – General Questions

Radiology and/or Radiotherapy Addendum

Anaesthetics Addendum

Procedure Private Practice NHS


Dermatology Addendum

Gastroenterology Addendum

General Surgery Addendum

Area of Surgery Private Practice NHS


Gynaecology Addendum

Neurosurgery Addendum

Bariatric Addendum

Procedure Private Practice NHS


Pain Management Addendum

Procedure Private Practice NHS


Orthopaedic & Trauma Addendum

Procedure Private Practice NHS


Cardiology Addendum

Cosmetic Addendum

Procedure Private Practice NHS

Procedure Private Practice NHS


Podiatry and/or Podiatric Surgery Addendum

Vascular Surgery Addendum

Procedure Private Practice NHS


Additional Information


Your documents will be emailed to your registered email address and be available to download in your client area. Premium Medical Protection works hard to reduce its carbon foot print and help the planet. All your information is available electronically in your client area.