Individual Practitioners Private Practice


Disclosure


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

Premium Medical Protection provides cover only 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 offer cover and you should not continue with the application. Please note you will be required to provide a confirmed claims experience covering your private practice for the past 10 years.

Premium Medical Protection does not provide cover for Obstetrics, General Practitioners and Paramedics amongst others.

1. Disclosure

You are now making an application for 'Professional Medical Indemnity Insurance' as required by English Law and the Channel Islands when practising in the UK as a medical professional. Any ‘material fact’ must be disclosed to Insurers. A ‘material fact’ is any information which may alter or affect the judgement of an Insurer in assessing the risk. Additionally, any ‘material changes’ must be disclosed to Insurers. A ‘material change’ is any information which may alter or affect the judgement of an Insurer that has not previously been disclosed as a material fact. Any such material changes need to be disclosed right up to the time that cover comes into effect, and would include any changes arising after submission of the proposal.

If you are in any doubt whatsoever as to whether or not a fact or change is “material,” you should disclose it to Insurers.

Failure to disclose all “material facts” or “material changes” prior to the policy coming into effect could lead to the policy being void and/or a claim not being paid.

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.

2. Presentation

Failure to provide all ‘material facts’ and/or notify all ‘material changes’ may cause the contract of insurance to be void and may result in Insurers repudiating liability entirely.

This Proposal 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. Where available, brochures, standard contract conditions, conditions, agreements and letter of appointment should be provided.

Failure to present Insurers with information in an appropriate manner may adversely influence the ability of Insurers to offer terms.

3. Guidance

If in doubt as to the meaning of any question contained within this proposal form or the issues raised in 1) Disclosure and/or 2) Presentation, advice should be sought from Premium Medical Protection in the first instance. On completion of this application form, you will be sent a terms of business document. Premium Medical Protection is an appointed representative of Harley Street Insurance Group Limited, 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 on line will be emailed to you for signing. 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. Underwriters require signed copies of all applications for all quotes to be valid.

4. Provision of Run Off Cover

Please note that terms and conditions 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.

5. Your Data

All information about you and your insurance is confidential and will only be passed to Lloyd's Insurance Brokers, Insurers and their agents or representatives for quotation and claims administration purposes. We only use and disclose the information we have about you in the normal course of arranging and administering your insurance, to provide you with information about other products and services that we feel may be appropriate to you or where we are required to do so by law, or by virtue of our regulatory requirements. For the purposes of quotation and claims administration, information we have about you may be transferred to agents or representatives of Insurers outside the European Economic Area (EEA) in countries whose data protection laws differ from that of the EEA. In this case any transfer of information will be made in accordance with the provisions of the Data Protection Act 1998. We are registered under the Data Protection Act 1998 and we undertake to comply with the Act in all our dealings with your personal 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


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Add

Section C – Indemnity



Previous Insurer Start Date Limit of Indemnity Excess

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Section D – Activities


If none, please enter a zero.

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Section E – General Questions


Radiology and/or Radiotherapy Addendum



Procedure Split %

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Procedure Split %

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Urology Activity Addendum



Sub-Speciality Private NHS

Add

Area of Surgery Approximate number of operations you perform each year in private practice Approximate % of your work in each area of surgery in private practice Approximate % of your work in each area of surgery in the NHS

Add

Anaesthetics Addendum


Dermatology Addendum


Gastroenterology Addendum


General Surgery Addendum



Sub-Specialty Private NHS

Add

Area of Surgery Approximate number of operations you perform each year in private practice Approximate % of your work in each area of surgery in private practice Approximate % of your work in each area of surgery in the NHS

Add

Gynaecology Addendum


Neurology Addendum


Neurosurgery Addendum


Oncology Addendum


Ophthalmology Addendum


Orthopaedic & Trauma Addendum



Area of Surgery Approximate number of procedures you perform per year in private practice Approximate % of your work in each area of surgery in private practice Approximate % of your work in each area of surgery in the NHS

Add

Pathology Addendum



Tests Percentage

Add

Plastics/Aesthetic/Reconstructive Surgery Addendum



Activity Number of procedures undertaken per year

Add

Activity Number of procedures undertaken per year Product / System Used

Add

Podiatry and/or Podiatric Surgery Addendum


Vascular Surgery Addendum


Additional Information


Declaration