MEDICAL MALPRACTICE INSURANCE AUXILIARY QUESTIONNAIRE PLASTIC SURGEONS
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1 MEDICAL MALPRACTICE INSURANCE AUXILIARY QUESTIONNAIRE PLASTIC SURGEONS
2 This auxiliary addendum must be completed, signed and dated on each page by the proposer. All questions must be answered (if necessary, comment as not applicable or none ) Please insure that you have checked and reviewed the completed documents before returning. Please advise below which activities you are qualified and licensed to practice in and for which you require indemnity Arm Reduction / Arm Lift / Thigh / Buttock Lift Breast Augmentation Reduction Mastopexy Reduction Inverted Nipple Corrected Gynaecomastia Implant Removal Eyes Upper Blepheroplasty Lower Blepheroplasty Facial Cheek Implants Chin Implants Nasal Implants Pinnaplasty Brow Lift Threadlift Mini Lift Full Facelift Initial Date Medical Malpractice Insurance Auxiliary: AQGS1 Page 2 of 7
3 Implants except female breast Buttock Calf Gluteal Pectoral Other (please state) Mole Removal Liposuction Wet Dry Nose Rhinoplasty Septo-Rhinoplasty Stomach Abdominplasty Mini Full Umbilicoplast Vaginal Clitoral Hood Reduction Labioplasty Vaginoplasty Vaginal Tightening Medical Malpractice Insurance Auxiliary: AQPS1 esrcnaqps1 Page 3 of 7
4 Varicose Veins Penile Enhancement Botulin Toxin A/ Hyperhydrosis Chemical Peel Carboxytherapy Is the patient s medical history always obtained from their own GP prior to treatment Yes No Do the clinic(s) you undertake work for select, purchase and supply to you all the inserts, fillers, disposables etc. that you then use in any procedure Yes No Dermal Fillers (Temporary/Semi Permanent) FDA Approved injectables only as listed below Cosmoderm Cosmoplast Cymetra, Restylane Juvederm Juvedern Ultra Ultra plus Radiesse Sculptra Evolence Perlane Hydrelle Pravelle Silk Medical Malpractice Insurance Auxiliary: AQPS1 esrcnaqps1 Page 4 of 7
5 Laser Hair Removal: Non Ablative IPL, LHE, LED (must be CE marked equipment) Ablative (must be CE marked equipment) Laser Lipolysis Non Aspirate Laser Lipolysis Aspirate Mesotherapy Microdermabrasion Schlerotherapy Is there any other you provide not listed above? If so please provide full details here: Medical Malpractice Insurance Auxiliary: AQPS1 esrcnaqps1 Page 5 of 7
6 Declaration I declare, after enquiry, that the statements and particulars contained in this proposal form, together with any other information supplied by me, is true and that I have not mis-stated or suppressed any material facts. I agree that this proposal form, together with any other information supplied by me, shall form the basis of any contract of insurance affected thereon. I undertake to inform Insurers promptly of any material alteration to these facts occurring before the completion of the contract of insurance and throughout any period of insurance (and any extension thereto). Signing this proposal form does not bind the proposer to complete this insurance. Name Date Signature Position Remember To initial and date each page of this auxiliary questionnaire Data Protection Act All personal information supplied by you will be treated in confidence by Euna Underwriting Limited and will not be disclosed to any third party except where your consent has been received or where permitted by law. In order to provide you with products and service this information will be held on data systems of Euna Underwriting Limited. Medical Malpractice Insurance Auxiliary: AQPS1 esrcnaqps1 Page 6 of 7
7 Euna Underwriting Limited America House, 2 America Square London EC3N 2LU Phone: info@euna.com Euna.com Authorised and Regulated by the Financial Conduct Authority FRN Registered in England and Wales Number at 5th Floor Minories House 2 5 Minories, London EC3N 1BJ Euna Underwriting Limited are an Appointed Representative of European Specialty Risks Limited FRN
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