Medical Professional Liability Insurance for AfPP Members

Transcription

1 Medical Professional Liability Insurance for AfPP Members Page 1 of 8 Medical Professional Liability Insurance for AfPP Members PLEASE ANSWER ALL QUESTIONS AS FULLY AS POSSIBLE Your application cannot be processed unless all the relevant shaded questions are completed: Please note, that cover will not be provided until Underwriters have reviewed the information provided Important Guidance Every question must be answered accurately and fully. A quotation by the Underwriters may be refused or delayed if any answers are incomplete. If you are unsure about any question or if you need any assistance in completing this Proposal, please contact the AfPP on This guidance explains about the duties of disclosure required in completing this Proposal and some of the more important aspects of the insurance contract. It is important that the answers are full and accurate. However, submitting this Proposal does not bind the Proposer or the Underwriters to complete a contract of insurance. This Proposal uses certain terms defined within the corresponding Policy wording and which should be read in conjunction with this Proposal. If you are viewing this online, using the web based Proposal Form, where a term is defined you may click on the term to see its definition. If you would like a copy of a specimen Policy wording, please contact the AfPP. This Proposal must be completed by the Proposer. This Proposal is made by the Proposer to the Underwriters to enter into a contract of insurance and the Proposer MUST have the requisite authority on behalf of the Insured to complete and sign it. Every question must be answered accurately and fully. NONE or NOT APPLICABLE should be entered if any questions do not relate to the Insured. A quotation by the Underwriters may be refused or delayed if any answers are incomplete. If you are unsure about any question or if you need any assistance in completing this Proposal, please contact the AfPP. The Proposal and the insurance Policy shall be considered as one sole document. In the event of any conflict between the Proposal and the policy, the Policy shall prevail. This Proposal Form must be completed in full by the Proposer and must be submitted to the AfPP. The on-line submission of this Proposal to the AfPP will have the same legal effect as if you had physically printed, signed and dated the Proposal form. 1. As a regulated activity and in compliance with Financial Services Regulations, please tick this box to confirm that you have reviewed both the cover you are purchasing and the AfPP document entitled Keyfacts about our insurance services by visiting the Medical Liability Insurance section on our website: I Agree 2. By ticking this box, you have confirmed that you have read and understood the contract of insurance (the Master Policy wording) that you are entering in to. The Master Policy wording may be viewed by visiting the Indemnity section on the AfPP website. I Agree

2 Medical Professional Liability Insurance for AfPP Members Page 2 of 8 Personal Details 1. Preferred Title Dr Mr Mrs Ms Miss Professor 2. First Name(s) / Forename(s) 3. Surname / Last name 4. AfPP Membership Number 5. Address 6. Postal Code 7. Preferred Contact Telephone Number 8. Address 9. Job Title

3 Medical Professional Liability Insurance for AfPP Members Page 3 of Specialisation/s 11. Medical Qualifications Medical Services 1. Are you involved in any work outside of the NHS i.e. private work, for which you require cover? This includes any work carried out for an agency, private organisation or directly for a Medical Practitioner / Surgeon / Consultant. a. Please select what type of work: (Tick all that apply) Private Hospital Agency(s) Directly for a Medical Practitioner / Surgeon / Consultant Please note that if you are paid directly by a Medical Practitioner / Surgeon / Consultant you will need to select the higher 3,000,000 Limit, within the Insurance Questions section. b. Please provide names of Agency, Hospital and Consultant 2. Maternity and/or Obstetrics Work Please note that cover is not provided under the Policy for any midwifery services provided by a registered Midwife. For further information, please contact the AfPP. I confirm that I am NOT a Midwife nor provide any midwifery services. 3. Are you involved in any advanced role for which you require cover? This will include any work carried out for an agency or private organisation.

4 Medical Professional Liability Insurance for AfPP Members Page 4 of 8 a. If '', please select the role below Nurse Practitoner Nurse Consultant Advanced Nurse Practitioner GP Practice Nurse Surgical Care Practitioner Clinical Nurse Specialist Specialist Nurse n-medical Prescribers Surgical First Assistant / Advanced Scrub Practitioner Other 4. Do you perform or do you expect to perform any activities outside of Great Britain, rthern Ireland, Channel Islands or the Isle of Man. Corporate Information 1. Do you operate as a Limited Company? If '', then give full details here: a. The full name of your company: b. Current Turnover - If your company is new, please indicate an estimate: , , , , , , , , or over c. Is this purely for personal financial reasons? d. Do you have any employees other than yourself?

5 Medical Professional Liability Insurance for AfPP Members Page 5 of 8 I. If '', please specify below: One Employee (only) - NOT providing any Medical / Clinical Services More than One Employee Insurance Questions 1. Please select the Limit of cover you require 3,000,000 Any One Claim (including costs and expenses) and In the Annual Aggregate (including costs and expenses) for members working directly for and/or on behalf of, and who are paid directly by any medical practitioners / surgeons / consultants in the private sector for per year inclusive of 6% Insurance Premium Tax, or per month if paying by direct debit 3,000,000 Any One Claim (including costs and expenses) and In the Annual Aggregate (including costs and expenses) for per year inclusive of 6% Insurance Premium Tax, or 7.15 per month if paying by direct debit 1,000,000 Any One Claim (including costs and expenses) and In the Annual Aggregate (including costs and expenses) for per year inclusive of 6% Insurance Premium Tax, or 5.30 per month if paying by direct debit The overall Annual Aggregate is limited to a maximum of 6,000,000 In the Annual Aggregate (including costs and expenses) for all members of the AfPP. 2. Do you currently have Medical Malpractice Insurance through the AfPP scheme? a. If '', do you currently have any other Medical Malpractice Insurance? If you have answered yes, please state your retroactive date below and also attach your current Evidence of Insurance / Certificate of Cover to this form. A retroactive date cannot be considered without receipt of this. The retroactive date requested must match the date stated on your current Evidence of Insurance / Certificate of Cover. I. RETROACTIVE DATE: Q What is my retroactive date? A This is the date you originally took out any type of suitable Claims made medical insurance cover (providing there have been no gaps). Underwriters will confirm if your Retroactive Date is acceptable.

6 Medical Professional Liability Insurance for AfPP Members Page 6 of 8 II. Please provide a copy of your Existing 'Evidence of Insurance' If ing please include a scan or if posting this Proposal, a photocopy 3. Please specify the Date that you require this insurance to start from We can consider new applications for cover starting on any date within 30 days from submitting this form. Cover cannot be backdated. Previous Claims History 1. How does Cover Operate? Medical Professional Liability Insurance cover is written on a claims made basis. This means that any claims are dealt with under the terms of the policy in force at the time the claim is notified, not the policy that was in force at the time of the original error or omission that has led to the claim. For this reason it is important that you do not allow insurance cover to lapse as this will mean that you will be responsible for settling any claims notified during the period cover is not in force. Please keep the above in mind when completing your preferred start date of insurance and when considering the cancellation of any previous cover held. It is essential that we have plenty of time to deal with your request to confirm or decline cover before your existing insurance expires or is cancelled. I Understand 2. Have you had any claims, complaints, or incidents, which could give rise to a claim involving negligence, error or omission, or are you aware of any circumstances which may bring such a claim or suit made against you? Underwriters consider a Claim to have been made when an Insured has received either an oral or written communication from or on behalf of a patient or any third party or a request by or on behalf of a patient for copies of medical records. a. If '', then give full details here, including all payments and reserves:

7 Medical Professional Liability Insurance for AfPP Members Page 7 of 8 Declaration 1. I HAVE READ, UNDERSTOOD AND AGREE WITH THE MATERIAL STATEMENTS DECLARATION: The Underwriters will rely upon the material statements and information supplied in the Proposal and therefore it is important that every matter which is known or ought reasonably to be known by the Insured and that a reasonable person in the circumstances could be expected to identify as relevant and/or material to the risk being Insured are disclosed in the Proposal before this Policy is entered into and at any renewal, extension, variation or reinstatement of the policy. In the event of any material changes during the Policy Period, such as a change in qualification or role, it is important that these material changes are notified to the Underwriters immediately in writing, as these changes will affect the coverage provided by this policy. In the event of unintentional non-disclosure, the Underwriters may at their absolute discretion refuse to cover additional exposure to that which was disclosed; or charge a reasonable additional premium; or avoid the contract. In the event of intentional or fraudulent failure to comply with the duty of disclosure, or fraudulent misrepresentation to the Underwriters, the Underwriters may avoid the contract. 2. I HAVE READ, UNDERSTOOD AND AGREE WITH THE IMPORTANT NOTICES DECLARATION: Acceptance of Terms Upon acceptance of the Underwriters' terms and conditions, it is important that the premium is paid in accordance with the payment terms, as non-payment of the premium will result in the Policy being declared void from its inception date. Waived Recourse Rights and Rights of Subrogation This Policy includes a provision that will exclude or limit Underwriters' liability in respect of loss where you are a party to an agreement that excludes or limits your rights to recover damages from a person in respect of that loss. Underwriters refer you specifically to clause 4.6 of the Policy wording. Legal tices EU Residents: The parties making this contract are free to choose the law applicable to this contract. Unless the Proposer indicates otherwise in the Proposal, the contract shall be subject to the law of the country of domicile of the Insured. In any event, the Proposer is advised that the Underwriters are subject to regulation by Lloyd's of London and ultimately by the Financial Conduct Authority in the United Kingdom. n-eu Residents: If the Proposer has requested and the Underwriters have accepted that this contract be subject to the laws and jurisdiction of the country of domicile of the Insured, then if any of the terms of the Policy are in conflict with any applicable statute, the Policy terms shall be deemed amended, in order to comply with the minimum provisions of such law. This Proposal is not intended for use by residents of Australia or the United States of America or of any territories which are subject to the laws of the United States of America. The MPLC is an underwriting intermediary licensed in Gibraltar by the Financial Services Commission under licence number FSC00659B. The MPLC has notified the FSC of its intention to provide cross border services in accordance with the requirements of the EU Insurance Mediation Directive. The MPLC's insurances underwritten by certain by underwriters at Lloyd's. For further information, please visit 3. I HAVE READ, UNDERSTOOD AND AGREE WITH THE COMPLAINTS DECLARATION: The MPLC aims to provide a first class professional service. Should you have any questions, concerns or complaints please contact Bluefin Insurance Services Limited on

8 Medical Professional Liability Insurance for AfPP Members Page 8 of 8 Alternatively, you may wish to contact The MPLC by writing to: Managing Director The Medical Professional Liability Company Limited Regal House, Queensway, P.O. Box 1446, Gibraltar complaints@the-mplc.com In the event that you are unable to resolve the situation you may, in certain circumstances, contact the Policyholder & Market Assistance Department at Lloyd's. Policyholder & Market Assistance, Lloyd's Market Services, One Lime Street, London EC3M 7HA Tel : +44 (0) ; Fax : +44 (0) ; complaints@lloyds.com Finally, in the event that the Policyholder & Market Assistance Department is unable to resolve your complaint, it may be possible for you to refer it to the Financial Ombudsman Service (FOS) or other local dispute resolution body. Further details will be provided at the appropriate stage of the complaints process. 4. I confirm that I am not subject to any Sanctions and that I am not listed on either of the HM Treasury Sanctions List or OFAC Specially Designated Nationals List. 5. You must bring to the attention of Insurers any material fact that arises between submitting this form and date of the commencement of the insurance. Failure to provide all material facts may cause the contract of insurance to be void and may result in insurers repudiating liability entirely. A material fact is any information which may alter the judgement of an insurer in assessing the risk. Please provide here any additional information that may be material to the Underwriters 6. I declare that I have read and understood the guidance notes and important notices and that after full examination, all statements and particulars contained in the Proposal and any uploaded documents are true and that no information whatsoever has been withheld that might increase the risk of the Underwriters or influence the acceptance of this Proposal and should the above particulars alter in any way, I will advise the Underwriters immediately. I 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 cancelling the Policy in every respect. I agree and accept that this Declaration shall be the basis of the contract between both parties if entered into. Full Name: Signature: Date: