I. Assistance and Air Ambulance Services. "',, " 'Proposal Form ', " ;,.' '"~;~~ Medical Malpractice Insurance

Transcription

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2 PLEASE REA THESE GUIANCE NOTES BEFORE COMPLETING THE PROPOSAL FORM. Where further information is required please refer to Crispin Speers & Partners,. This Proposal Form is for a CLAIMS MAE policy. A CLAIMS MAE policy only responds to "claims" made against the Insured and notified to Underwriters during the period of insurance.» This Proposal Form must be typed, or completed in ink and signed and dated by the Proposer., Please answer every question fully, and state "NIL" or "NONE" as applicable. Incomplete answers may not be accepted and can delay quotation.,. Where more than one location or Company/Firm is to be included in the quotation, please complete a separate Proposal Form for each location or Company/Firm. r Please submit, with the Proposal, all relevant information including Financial Report and Accounts, Brochures, Consent Forms etc. NOTE: This information may also be required for compliance purposes. r Should there be insufficient room in the Proposal Form for full details, please attach further information on signed and dated sheets, wherever possible following the same format and question number.,. It is the duty of the Proposer to disclose all material facts to Underwriters. Where this is omitted, the Underwriters may avoid their Obligation under the Policy.

3 1.0 Full Name of the Insured: 1.1 Trading name if different from above 1.2 How long has the establishment been trading under the above name? I 2.0 Has the Insured or its principals engaged in any Healthcare activities under a different title in the last 5 years. v If Yes, please provide details on a separate sheet identifying: Title, Trading and Registered Addresses, Nature of Services 3.0 Full Trading address: Telephone no. Fax no. . Website. 3.1 Registered office if different from above: I Telephone no. Fax no. 4.0 Please name ultimate Owner or Holding Company: I~ Please identify any corporate or private entity of either USA or Canadian origin, that has any ownership or interest in either the Insured or the Insured's ultimate owner or holding Company and their percentage holding. 1'--- _ 4.2 Length of operation by present ParenUOwner: I Yrs Mths 5.0 Please state your Gross Fee IncomelTumover/Gross Receipt: Last Financial Year Ic J Estimate Current Financi~ ' ' 5.1 Please state the approximate number of patients/clients: Last Financial Year] _ Estimate Current Financi~ ~----

4 6.0 Please give a full description of your business activities for which cover is required This question must be answered Are you licensed and registered in accordance with the applicable regulatory body or law to practise those procedures at the addresses specified in Question 3 for which indemnification is required? Yes If No, please provide a full explanation on sheet provided: 7.1 Please identify your membership or registration with Association or Professional Bodies or Licensing Authorities Has membership or registration of the above ever been suspended, withdrawn, amended, declined or had any conditions attached? Yes 0 NOO If Yes, please provide full details on the sheet provided 7.3 To help us understand your business can you segment all patient movements during the last Road Escort Commercial Air Ambulance Only Airlines Ambulance International International (ex USA) (inc USA) omestic Total you employ or contract your own doctor? U Yes UNo If Yes, do they have adequate insurance in their own name? 7.5 If you subcontract the medical services do they provide you with arp'-ll'fof of 0 indemnification? U Yes No

5 PLEASE NOTE THAT THIS POLICY IS ESIGNE TO COVER CLAIMS MAE AGAINST THE INSURE. If cover is also required for claims made against registered medical/dental practitioners for work performed for the Insured, please supply a list of all such practitioners for whom coverage is required stating their name, d.o.b, qualifications and practice for each practitioner. In addition please confirm whether or not the practitioners are self employed by the Insured or self employed. 8.0 o you ensure and record that your medical staff are members of a Medical/ental efence or9 tion, rec ed by your National Medical Association, or are otherwise fully insu for t. wn Malpractice? If Yes, please refer to the Note above. Yes No 1 ---' 9.0 Please state number of Air Ambulances in operation and aircraft details ' 9.1 Please state number of air crew members per Air Ambulance ' 9.2 Please state minimum acceptable qualifications of crew members ' 9.3 In which countries do you anticipate operating 9.4 Estimated number of repatriations each year 10.0 PREVIOUS INSURANCE HISTORY Please refer to avid Stirling or Sara Tol/eyat Crispin Speers & Partners Ltd if you are in any doubt as to what is being asked of you in this ::~~io1 insured? I Has prior coverage been on a Claims Made Basis? Yes No If Yes, what is the Retroactive ate

6 10.3 What are the present policy limits of insurance? What is the amount of self insured excess for each policy? : 10.5 Has any application for this type of insurance cover ever been: eclined, Cancelled or Subject to Special Terms O o If Yes, please provide details 11.0 PREVIOUS CLAIMS HISTORY 11.1 List all claims made against the Insured during the last 10 years, whether insured or not, for all Sections of cover requested. If none, please state "None" ate of Circumstance I Complaint etails including nature of the Complaint and details of the Complainant 11.2 List all circumstances/complaints which may give rise to a claim being made against the Insured for all Sections of cover requested. If none, please state "None" ate of ate of Amount Amount Amount etails including nature of the Incident Claim Claimed Paid Outstanding allegations details of Claimant 12.0 Have all of the above in question 11 a) been notified to your previous Underwriters? b) been accepted by your previous Underwriters? No No 13.0 Please indicate which limit(s) of indemnity you require quotations for: 1 million 2 million 3 million 4 million 5 million ~' Currency 1 _

7 Please use this space to record the answers to any questions for which additional space may be required, noting the appropriate question number

8 I/We declare and warrant that after enquiry all statements and particulars contained in this Proposal and addenda are true and that no information whatever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this Proposal and should the above particulars alter in any way. I/We will advise the Underwriters as soon as practicable. I/We understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of the Proposal may result in the Underwriters refusing to provide indemnity or voiding the policy in every respect. I/We hereby agree and accept that this eclaration shall be the basis of the contract between both parties if entered into. For and on behalf of I I Name of Proposer 1 _ Position 1 _ Signature " ated 1. I." '1"'