Medical Malpractice proposal form

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1 Medical Malpractice proposal form Instructions Please provide a full answer to every question. Please ensure that all answers are typewritten or printed in block letters within the spaces provided. A principal of the practice must sign and date this form and any separate sheets. 1 Name and address details Practice name (please include all names under which you practice) Main office address Telephone number Postcode: Your Employer s Registration Number (ERN) (also known as the Employer s PAYE reference) Contact address Number of branch offices Date established / / Length the practice has operated under present management Please list on a separate sheet all branch offices including addresses for which you are seeking cover. 2 General information 2.1 Have you ever carried out medical activities in any other name, been part of an amalgamation, merger or demerger or in any way had any material change to your activities? If, please provide full details below (or on a separate sheet). 2.2 Is there any corporate or private American or Canadian entity or Individual that has or has had an interest, ownership or control of you or your company? If, please provide full details below (or on a separate sheet). 2.3 Are you a member of or registered with any associations, professional bodies or self-regulatory organisations. If, please provide details below (or on a separate sheet). 2.4 Are you in possession of relevant licences and/or registrations(s) from the applicable regulatory body or as required by law? If, please provide full details below (or on a separate sheet). 2.5 Has any membership or registration with any such bodies (as detailed in 6 and 7 above) ever been refused on application, suspended, withdrawn or had conditions imposed? If, please provide full details (or on a separate sheet). 2.6 Who within your organisation is responsible for Clinical Risk Management? Name: Position: Date joined: / / Qualifications: Bluefin Professions Medical malpractice v3.0

2 3 Medical services information Please provide the following information: 3.1 Please provide details of your gross income / fees / turnover for the last two financial years and an estimated figure for the forthcoming financial year. Last Year Prior Year Current Year (E) UK Ireland Europe USA/Canada Rest of the World Total 3.2 Please provide a full description of your business activities and attach any sales and marketing brochures/literature about your business. 3.3 Please provide the percentage of your income derived from each of the disciplines below. Activity Percentage Activity Percentage Accident and/or Emergency % Hyperbaric Clinic / Services % Acquired Brain Injury Rehabilitation % Learning Disabilities % Addiction Treatment Centres % Medical Employment Agency % Alternative / Complimentary Therapy % Medical Repatriation % Ambulatory / Paramedic Services % Medical Training Institution % Antenatal Clinic % Nutrition/Slimming/Dietary % Beauty Therapy Clinic % Obstetrics & Maternity % Clinical Trials % Occupational Health % Cosmetic Surgery - invasive % Opticians / Optometry % Cosmetic non invasive % Out of Hours Primary Care Services % Counselling % Palliative Care % Dentistry % Pathology / Laboratory Services % Diagnostic and Scanning Services % Pharmacy % Dialysis Services % Psychiatric % Domicilliary Care % Sports Medicine / Injury % Elderly Care % Surgery - Minor % Eye Surgery Laser / Refractive Eye % Surgery Major % Eye Surgery Other % Other (please provide details below):- % Fertility Services % % GP / Primary Care Services % % Health and Fitness Centre % % Total 100% Please provide details of activities if listed under Other above.

3 3.4 Do you have any inpatient facilities? If, please provide details below. Type of Bed Average Daily Occupancy - % Number of Beds Acute Care Beds % Acute Psychiatric Beds % Acquired Brain Injury Rehabilitation Beds % Addiction / Rehabilitation Treatment Beds % Bassinets, Cribs and Cots % Elderly Care Beds % Hospice / Palliative Care Beds % ICU / ITC Beds % Learning Disability Beds % Nursing Home Beds % Psychiatric Rehabilitation Beds % Total % 3.5 Do you undertake any outpatient/day case procedures at your facilities? If, please advise. i) The number of procedures ii) The income generated from these procedures 3.6 Do you own or operate any of the following i) Pathology Laboratories ii) Ambulances or patient transport vehicles iii) Air Ambulances iv) A blood bank that procures, tests and distributes blood or blood products v) CAT scanners, MRI equipment or similar If, is there a maintenance agreement in force with a third party? 3.7 Do you have any Medical or Nursing teaching facilities and/or do you provide training or tuition to anyone other than your own employees? If, please provide details below. 3.8 Do you anticipate any material changes to your activities in the forthcoming 12 months? If, please provide details below. 3.9 Do you publish advice or offer medical diagnosis over the internet or any other electronic media that is available to patients? If, please provide full details below.

4 3.10 Please advise the number of persons involved in your business in each of the following categories: Employee Type Full and Part Time Employees Self Employed Bank / Agency Staff Doctors i) Cosmetic Surgeons ii) Orthopaedic Surgeons iii) Other Surgeons (Specify below) iv) Obstetricians v) Anaesthetists vi) Residential Medical Officers (RMO) vii) Psychiatrists viii) Radiologists ix) General Practitioners x) Other (Specify below) Other Medical Personnel i) Laboratory Technicians ii) Pharmacists iii) Clinical Scientists/Specialists iv) Registered Nurses v) Registered Midwives vi) Nurse Practitioners vii) Radiographers viii) Attendant carers ix) Complementary Professionals x) Paramedics xi) Other (Specify below) n Medical Personnel i) Directors / Partners / Principals ii) Clerical/Administration iii) Other Employees (Specify below) 3.11 Do you require that all professionally qualified healthcare staff, listed above in Q3.10 i) Carry their own medical Professional Indemnity Insurance or maintain Indemnity via a Medical Defence Organisation? ii) Provide evidence of this coverage on an annual basis, as part of your practitioner credentialing processes? iii) Are registered with and a subscribing member of a Medical Institute or other professional body? If, please provide details below Do you undertake the following for all staff: i) Obtain references and check the validity of any professional qualifications? ii) Undertake appropriate police checks on all staff (including temporary or contract)? iii) Ensure that all staff are adequately trained and competent for their role?

5 iv) Ensure that all staff are adequately supervised under the appropriate management? If, please provide details below Do you operate, in part or whole, as an NHS Independent Treatment Centre or undertake any work for the NHS where liability is covered under the CNST Scheme? If, please provide details including the revenue relating to this work Do you sub-contact any work? If, please provide details of the nature of the sub-contracted work including any one off projects? 3.15 Do you enter into any written agreement, or operate under a standard form of contract or letter of appointment? If, please provide a copy Do you require all sub-contractors to maintain their own medical indemnity insurance cover at all times and for this to be evidenced? If, please provide details below Do you provide facilities for the sterilisation of instruments in accordance with current guidelines and do you ensure that cross infection control methods are employed? If, please provide details below Do you comply with the current guidelines for the safe collection and disposal of any clinical/medical waste products? If, please provide details below Do you have a protocol for Needlestick injuries? If, please provide details below Do you maintain and will you continue to maintain accurate descriptive records of all Medical Services provided for a period of at least ten (10) years from the date of treatment, and in the case of a minor, for at least ten (10) years after that minor attains majority? If, please provide details below Is there any further information that should be made known to Underwriters so that they may form a proper estimate of the risk? If, please provide details below (including any part time activities, details of associated companies and/or links).

6 4 Claims Information Please advise the following: 4.1 During the last 10 years any claim has been made, defended or settled, or any malpractice or negligence has been alleged against you? 4.2 Are there any circumstances which may result in a claim against you or any prior corporate practice, predecessors in business or any present or former Partner, Principal or Director or Professional Practitioner? 4.3 Has any Partner, Principal or Director or member of staff has ever been subject to Disciplinary Proceedings for professional misconduct? 4.4 If you have answered to any of the above, please confirm that you have notified such matters to your current insurers. If, please explain why not below: 4.4 If you have answered to any of the above, please provide full details below (or on a separate sheet if you run out of space), complete information on all claims and circumstances, including full financial details. Please also provide dated copies of the claims sheets from any previous insurers. 5 Sanctions Do you have any connection to customers or suppliers operating in the following countries or are any form of product or service sourced from or passed through these countries or indeed any employees who would visit any of these countries on business: Iran, Syria, Belarus, South Sudan, Cuba, Democratic Republic of Congo, rth Korea, Somalia, Sudan, Zimbabwe, Russia, Ukraine, Crimea. 6 Disciplinary proceedings Has any proposer / director / partner of the business: (i) Been declared insolvent or bankrupt or been the subject of bankruptcy proceedings? (ii) Been the subject of a County Court judgment (or Scottish equivalent) or are there any proceedings pending? (iii) Been a director or partner in any business which is or has been the subject of a winding up or administrative order, or receivership or other insolvency proceedings? (iv) Had a proposal form declined? (v) Had an insurance cancelled? (vi) Had special terms imposed? (vii) Been convicted or charged with any criminal offence, or have a prosecution for such an offence pending? (viii) Been prosecuted or served with a notice of intended prosecution or a prohibition notice in connection with a breach or alleged breach of any health and safety legislation? If, please provide details:

7 7 Indemnity Please advise the following: 5.1 Please provide full details of all previous Medical Malpractice cover: Limit of Indemnity Excess Premium Name of Insurer Renewal Date / / 5.2 What is the amount of indemnity now required? 5.3 Has prior cover been on a CLAIMS MADE basis? If, what is the current retroactive date? / / 5.4 Has there been continuous cover in place since the retroactive date? 5.5 Has any proposal for similar insurance made on behalf of the proposer s business, any predecessor of the business, or any Partner, Principal, Director even been declined or has such insurance ever been cancelled, had renewal refused or had any special terms imposed (other than general market increases)? If, please provide full details below. People consulted in completion of the form Please list below the people you have consulted to assist with the completion of this form, including any external providers: Name Position Location Please continue on a separate sheet if necessary. Confirmation Your duty to make a fair presentation of the risk You must make a fair presentation of the risk to us when you take out, renew or amend your policy. A fair presentation requires you to tell us about all facts and circumstances which may be material to the insurance or sufficient information to put a prudent insurer on notice that further enquiries are needed, in a clear and accessible manner. Material facts are those which are likely to influence an insurer in the acceptance or assessment of the terms or pricing of your policy. If you are in any doubt as to whether a fact is material, you should tell us about it. If you fail to make a fair presentation of the risk, where that failure is deliberate or reckless, the insurer may treat your policy as if it had not existed, refuse to pay any claims and keep the premium paid. Where the failure is not deliberate or reckless but the insurer would not have accepted the policy had you told them about a material fact or circumstance, the insurer may treat your policy as if it had not existed and refuse to pay any claims but must return the premium. In other cases, the insurer may only pay part of the value of your claim or impose additional terms. For these reasons, it is important that you check all of the facts, statements and information set out in the documentation provided by us are complete and accurate, and that you answer any questions completely and accurately. If there is more than one person involved in your business or employed by you, you should check with them, where appropriate, that the facts and statements that you make are complete and accurate. If any of the facts, statements and information in this document, or any additional information provided are incomplete or inaccurate, you must contact us immediately. Failure to do so could invalidate your policy or lead to a claim not being paid. I declare that the above statements and particulars are true, full enquiry having been made, and I have not omitted, suppressed or misstated any material facts and undertake to inform the insurer of any change to any material fact. I understand that the information provided will be used by the insurer and/or their agents to arrange and administer the insurance and in handling claims which may necessitate sharing information with third parties and that information may be shared with business partners to deliver any additional services provided with this insurance. A copy of this proposal should be retained by you for your own records

8 This form must be signed by a principal of the firm Signature: Date: / / Print name: Position: Please return this application form along with any other supplementary information sheets to the contact details on the covering letter. Bluefin Professions is a trading name of Bluefin Insurance Services Limited. Registered Office: 1 Tower Place West, Tower Place, London, EC3R 5BU. Registered in England : Authorised and regulated by the Financial Conduct Authority Bluefin Insurance Services Limited