Quotation Request

Individual Practitioners Private Practice

Disclosure

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 as per the Insurance Act 2015: 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:

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
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. Please ensure that you read your policy carefully and that you understand your obligations in this regard.

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 in relation to permanently ceasing Private Practice – for terms and conditions, please refer to Clause 5.4.

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.

I confirm I have read and understood the above.

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.

Title

First Name

Surname

Any other name(s) previously used?

Yes No

Telephone Number

Mobile Number

Correspondence Email

If different from your username.

Correspondence Address

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

Postcode search

Line 1

Line 2

Town / City

County

Postcode

Online Account

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.

Confirm email

Password

Confirm password

Section A – Personal Details

Date of birth

GMC registration number

Do you operate a Limited Company or other entity?

Yes No

Where did you hear about PMP?

Please Specify

Who recommended you to PMP

Please provide their Policy Number

Please specify which conference

Section B – Indemnity

1. Please advise the date that cover is required

2. What is the amount of indemnity required?

3. Please enter the date you started UK Private Practice

4. If you are just beginning in Private Practice or your current Indemnifier is the MDU, MPS or MDDUS would you like to receive a quote for an Occurrence Policy?

Yes No

5. Please provide full details of previous cover – please include all since qualification: Add another row by selecting the "Add another" link

Previous Insurer	Start Date	End Date	Limit of Indemnity	Excess	Expiring Premium
Previous Insurer	Start Date	End Date	Limit of Indemnity	Excess	Expiring Premium	Remove

Add

Section C – Activities

1. Please advise which area of medicine you require indemnity for

2. Please select any locations where you carry out Professional Services from the following list. If no relevant healthcare group is present or you only work in independent private hospitals please select "Other".

Remove

Add

Please give details of other hospitals:

3. Please advise your Total Gross Income for the past 12 months from Private Practice:

If none, please enter a zero. Please only use whole numbers to the nearest £1. Please only include income that is not already indemnified elsewhere.

Total Gross Non-Surgical Income

Total Gross Surgical Income

Of which is Consultations

Of which is Cosmetic

Of which is Medico-legal

Of which is Paediatric (under 18's)

Of which is Performed outside the UK

Of which is Performed outside the UK

Of which is Other (Non surgical procedures such as scans or injections)

Remaining surgical

Please provide details of Non-Surgical 'Other' Income:

Total Gross Annual Income from Private Practice

4. Do you have any contracts or formal agreements in place to provide ongoing medical services, including pre-employment screening, for any professional sports team or for professional sports people?

Yes No

5. Are you involved in any activities that require you to travel outside the United Kingdom, the Channel Islands or the Isle of Man for which you require cover?

Yes No

6. Do you have any other work which is covered by another professional liability policy?

Yes No

Radiology and/or Radiotherapy Addendum

1. Do you undertake (and/or read) any antenatal/obstetric ultrasound scanning at 20 weeks gestation or more in private practice?

Yes No

2. Do you undertake teleradiology?

Yes No

3. Do you perform any interventional procedures or minimally invasive image-guided procedures including, but not limited to, angioplasties, stenting, embolization, radiofrequency ablation, vertebroplasties, nephrostomies in private practice?

Yes No

Anaesthetics Addendum

1. Please provide a percentage split of your private practice between the following procedures which you anaesthetise patients for:

Obstetric Procedures:

Spinal Surgery:

Bariatric Surgery:

Cardiothoracic Surgery:

2. Please indicate the number of procedures you have performed in the prior 12 months and anticipate performing in the next 12 months in private practice:

Procedure	Prior 12 months	Anticipated for coming 12 months
Procedure	Prior 12 months	Anticipated for coming 12 months	Remove

Add

If you have selected Other please provide further details:

Gastroenterology Addendum

1. Do you perform weight control surgery (bariatric surgery)?

Yes No

General Surgery Addendum

1. Please indicate the number of procedures you have performed in the prior 12 months and anticipate performing in the next 12 months in private practice:

Area of Surgery	Prior 12 months	Anticipated for coming 12 months
Area of Surgery	Prior 12 months	Anticipated for coming 12 months	Remove

Add

If other selected, then please elaborate:

2. Do you perform weight control surgery (bariatric surgery)?

Yes No

Gynaecology Addendum

1. Please provide a % split of your private practice (by number of patients/procedures) between:

IVF Treatment %

Fertility investigation/consultation %

Cosmetic procedures %

Termination of Pregnancy (TOP) %

Antenatal %

Other - Major Surgery %

Other - Minor Surgery %

Other – Consulting (including any gynaecological ultrasound) %

Neurosurgery Addendum

1. What percentage of your gross income is derived solely from spinal injectibles? %

Bariatric Addendum

1. During the next year, please indicate the number of procedures you perform or anticipate performing in the NHS and private practice:

Procedure	Private Practice	NHS
Procedure	Private	NHS	Remove

Add

If you have selected Other please provide further details:

2. Please list the facilities where you will be performing bariatric surgery:

3. How many years have you been performing Bariatric Surgery?

Pain Management Addendum

1. Please indicate the number of procedures you have performed in the prior 12 months and anticipate performing in the next 12 months in private practice:

Procedure	Prior 12 months	Anticipated for coming 12 months
Procedure	Prior 12 months	Anticipated for coming 12 months	Remove

Add

If you have selected Other please provide further details:

Orthopaedic & Trauma Addendum

1. Do you consult on, or operate using, or have you in the past consulted on, or operated using any metal on metal implants (including hip implants) in private practice?

Yes No

2. Please indicate the number of procedures you have performed in the prior 12 months and anticipate performing in the next 12 months in private practice:

Procedure	Prior 12 months	Anticipated for coming 12 months
Area of Surgery	Prior 12 months	Anticipated for coming 12 months	Remove

Add

Other (please provide fully any other treatments offered, or any other infomation you believe will be relevant to your application).

Cardiology Addendum

1. Do you perform any Interventional Cardiology or electrophysiology procedures including but not limited to angioplasties, valvuloplasties, stenting, percutaneous valve replacement or repair or cardiac ablation?

Yes No

Cosmetic Addendum

1. Please indicate the number of procedures you have performed in the prior 12 months and anticipate performing in the next 12 months in private practice:

Minor Surgical

Procedure	Prior 12 months	Anticipated for coming 12 months
Procedure	Prior 12 months	Anticipated for coming 12 months	Remove

Add

If you have selected Other please provide further details:

Major Surgical

Procedure	Prior 12 months	Anticipated for coming 12 months
Procedure	Prior 12 months	Anticipated for coming 12 months	Remove

Add

If you have selected Other please provide further details:

2. Do your elective patients undergo a formal 'cooling off period' with no obligations to proceed, financial or otherwise, following the informed consent/counselling process, prior to undergoing surgery?

Yes No

Podiatry and/or Podiatric Surgery Addendum

1. Please provide a % split of your private practice (by number of patients/procedures) between:

Rear Foot %

Remainder of Foot %

Non-surgical consulting %

Other %

Vascular Surgery Addendum

1. Please indicate the number of procedures you have performed in the prior 12 months and anticipate performing in the next 12 months in private practice:

Procedure	Prior 12 Months	Coming 12 Months
Procedure	Prior 12 months	Coming 12 months	Remove

Add

If you have selected Other please provide further details:

Additional Information

Please provide any additional information on any other treatments offered, or any other information you believe will be relevant to your application, including any anticipated changes to your private practice in the next year.

Declaration

I declare that the statements and particulars contained in the proposal are true and that I/we have not misstated, misrepresented, failed to disclose nor suppressed any material facts. I agree that this proposal together with any other information supplied by me/us shall form the basis of any contract of insurance effected thereon. I undertake to inform Insurers of any material alteration to these facts occurring before completion of the contract of insurance. However, the duty to disclose material facts continues after the completion of the proposal form and throughout any period of insurance (and any extension thereto), upon which this proposal form was used as the basis of the contract of insurance. Signing this proposal does not bind the proposer to complete this insurance.

Tick here if you would like to receive your policy documentation by post

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.

Individual Practitioners Private Practice

Disclosure

Contact Details

Section A – Personal Details

Section B – Indemnity

Section C – Activities

Section D – General Questions

Radiology and/or Radiotherapy Addendum

Anaesthetics Addendum

Dermatology Addendum

Gastroenterology Addendum

General Surgery Addendum

Gynaecology Addendum

Neurosurgery Addendum

Bariatric Addendum

Pain Management Addendum

Orthopaedic & Trauma Addendum

Cardiology Addendum

Cosmetic Addendum

Podiatry and/or Podiatric Surgery Addendum

Vascular Surgery Addendum

Additional Information

Declaration