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: 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.

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.

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

Gender

Male Female

Nationality

Where did you hear about PMP?

Please Specify

Who recommended you to PMP

Please provide their Policy Number

Please specify which conference

Section B – Academic & Professional Details

Year of qualification

GMC registration number

Full registration date

Specialist Register Entry

Specialist Registration Date

Please list the private hospital groups with whom you have admitting rights

Remove

Add

Please give details of other hospitals:

Section C – 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. Have you had any breaks from your practice of 6 months or more over the past 3 years

Yes No

6. 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	Limit of Indemnity	Excess
Previous Insurer	Start Date	Limit of Indemnity	Excess	Remove

Add

Section D – Activities

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

1a. Please list any sub-specialisms or special interests you hold relevant to your private practice

2. Are you employed by the NHS as a consultant in the area of medicine selected above

Yes No

3. Please provide the % breakdown of your work between the following categories:

Employed NHS %

Private Practice %

4. Do you perform any surgical procedures, or consult on any conditions, in your private practice which you do NOT also perform/consult on in for the NHS?

Yes No

5. For the last financial year, please advise your:

If none, please enter a zero.

Total Gross Annual Income from Private Practice

Of which Medico Legal Work

Of which Consultations

Of which Cosmetics

Of which Other (please specify below):

If Other Income answered please give details:

6. Are you a Surgeon

Yes No

6a. Please provide an estimate of the number of Private Practice operations you undertake per annum (including Endoscopies)

7. Do you undertake any other work for which you require indemnification?

Yes No

8. Are you involved in clinical trials for which you require cover?

Yes No

9. Do you have any high profile clients or undertake work on any high profile people (defined as any person who is in the public eye or whose income is generated by public / media appearances)?

Yes No

10. Do you undertake any type of work for any professional sports team or for professional sports people including any pre-signing medical assessments?

Yes No

11. 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

12. Do you undertake any Paediatric Surgical work in the private sector?

Yes No

13. Do you operate a Limited Company or similar joint venture?

Yes No

Name	Job Title	Details of Job Role
Name	Job Title	Details of Job Role	Remove

14. Do you plan to retire from Private Practice in the next 36 months?

Yes No

Radiology and/or Radiotherapy Addendum

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

Procedure	Split %
Procedure	Split	Remove

Add

If you have selected Other please provide further details:

2. Of your diagnostic radiology work in private practice, please provide a further % split (by number of reads/patients) between:

Procedure	Split %
Procedure	Split	Remove

Add

If you have selected Other please provide further details:

3. Do you undertake (and/or read) any antenatal/obstetric ultrasound scanning at 20 weeks gestation or more (or the ‘Anomaly Scan’ where this takes place prior to 20 weeks) in private practice?

Yes No

4. How regularly does your diagnostic work in private practice undergo over-reads/clinical audit?

5. Please briefly describe the process you use for notifying a patient if there is a discrepancy in a radiographic interpretation requiring the patient to return.

Urology Activity Addendum

1. Do you work in the NHS as a Consultant Urological Surgeon with a Sub-Specialty Interest?

Yes No

2. Please indicate your sub-specialty (there may be more than one) and what % of your activity this comprises in your NHS and Private Practice:

Sub-Speciality	Private	NHS
Sub-Specialty	Private	NHS	Remove

Add

If you have selected Other please provide further details:

2a. Please list below the names of all the sub-specialty organisations of which you are a member.

3. Please state your activities related to Private (non-indemnified) and NHS (indemnified) work below:

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
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	Remove

Add

If you have selected Other please provide further information:

Dermatology Addendum

1. Do you perform strip excision hair transplants?

Yes No

2. What percentage of your gross income is derived from cosmetic work?

Gastroenterology Addendum

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

Upper Gastrointestinal surgery

Consulting %

Minor %

Major %

Lower Gastrointestinal surgery (including colo-rectal)

Consulting %

Minor %

Major %

Bariatric surgery

Consulting %

Minor %

Major %

Other

Consulting %

Minor %

Major %

If Other Income answered please give details:

General Surgery Addendum

1. Are you employed by the NHS as a Consultant General Surgeon with a sub-specialty interest.

Yes No

2. Please indicate your sub specialty(s) where applicable:

Sub-Specialty	Private	NHS
Sub-Specialty	Private	NHS	Remove

Add

If you have selected other please provide further information:

3. Please list below the names of all of the sub-specialty organisations of which you are a member:

4. Please state your activities related to private (non-indemnified) and NHS (indemnified) work below.

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
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 NHS	Remove

Add

If other selected, then please elaborate:

5. Do you perform any breast surgery in private practice?

Yes No

6. Do you perform abdominoplasties in private practice?

Yes No

7. 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

8. Do you perform any bariatric surgery in Private Practice?

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) %

Other - Major Surgery %

Other - Minor Surgery %

Other – Consulting (including any gynaecological ultrasound) %

2. If you carry out IVF work, what percentage of your gross annual income does this account for? %

3. Do you undertake Termination Of Pregnancy (TOP) in private practice?

Yes No

4. Are you involved in any post 20 weeks management of foetus?

Yes No

Neurology Addendum

1. Have you undertaken any Neurosurgery in private practice in the past?

Yes No

2. Have you undertaken any spinal procedures, either individually or as part of a team, in private practice in the past?

Yes No

3. Please indicate your sub specialty(s) or special interest(s) where applicable:

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

Lumbar Puncture %

Management of acute neurological emergencies %

Diagnosis or treatment of cancer %

Diagnosis and treatment of long term neurological conditions %

Other %

If you have answered Other please provide further details:

Neurosurgery Addendum

1. Of your spinal work in private practice, what percentage of your gross income is derived solely from Injectibles? %

Oncology Addendum

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

Clinical Oncology %

Oncological Surgery %

Radiation Oncology %

Other %

Ophthalmology Addendum

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

Laser Refractive Surgery (including pre-surgical consultations) %

Occuloplastic Surgery (including blepharoplasty) %

Cosmetic Occuloplastic Surgery (including blepharoplasty) %

Medical Ophthalmology (non-surgical consulting) %

2. Do you perform any other cosmetic procedures such as brow lift surgery or facial Botox injections in private practice?

Yes No

Orthopaedic & Trauma Addendum

1. Do you undertake emergency trauma surgery in private practice?

Yes No

2. 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

3. Do you monitor and adhere to the latest MHRA Medical Device Alerts regarding any metal on metal devices?

Yes No

4. Please provide a split of your private practice (by number of procedures) between:

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

Add

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

5. Do you undertake, or have you undertaken in the past any spinal procedures either individually or as part of a team, in private practice?

Yes No

6. What percentage of your gross income from private practice is derived from upper limb/hand surgery?

Pathology Addendum

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

Tests	Percentage
Test	Percentage	Remove

Add

If you have selected Other please provide further details:

Plastics/Aesthetic/Reconstructive Surgery Addendum

1. Are you both a Fellow of the Royal College of Surgeons, and a member of either BAAPS or BAPRAS?

Yes No

2. Are you a Breast Surgeon or Oncoplastic Surgeon?

Yes No

3. Do you perform any facial procedures other than injectibles?

Yes No

4. Please provide the following details:

4a. Please advise which area(s) of medicine you are qualified and licensed to practice and for which you require indemnity (SURGICAL)

Activity	Number of procedures undertaken per year
Activity	Number of procedures undertaken per year	Remove

Add

If you have answered Other please give details.

4b. Please advise which area(s) of medicine you are qualified and licensed to practice and for which you require indemnity (NON SURGICAL ACTIVITIES)

Activity	Number of procedures undertaken per year	Product / System Used
Activity	Number of procedures undertaken per year	Product / System Used	Remove

Add

If you have answered Other please give details.

5. Have you in the past consulted on, or operated using any products manufactured or partially manufactured, distributed, sold or certified by Poly Implant Prothèse (PIP) in private practice?

Yes No

6. 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 %

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

DeclarationCheck

Individual Practitioners Private Practice

Disclosure

Contact Details

Section A – Personal Details

Section B – Academic & Professional Details

Section C – Indemnity

Section D – Activities

Section E – General Questions

Radiology and/or Radiotherapy Addendum

Urology Activity Addendum

Anaesthetics Addendum

Dermatology Addendum

Gastroenterology Addendum

General Surgery Addendum

Gynaecology Addendum

Neurology Addendum

Neurosurgery Addendum

Oncology Addendum

Ophthalmology Addendum

Orthopaedic & Trauma Addendum

Pathology Addendum

Plastics/Aesthetic/Reconstructive Surgery Addendum

Podiatry and/or Podiatric Surgery Addendum

Vascular Surgery Addendum

Additional Information

Declaration