PROFESSIONAL INDEMNITY INSRUANCE - smu.uk.comsmu.uk.com/files/smu_downloads/Proposals/MedMal_2014.pdf · Gender Re-assignment YES/NO Keyhole YES/NO Organ Transplant YES/NO Other Major

PROFESSIONAL INDEMNITY

PROPOSAL FORM

med

ical malp

ractice

2

PLEASE READ THE FOLLOWING BEFORE

COMPLETING THIS PROPOSAL FORM:

TO PRESENT A CLEAR AND UNAMBIGUOUS PICTURE AND TO ENSURE THAT

UNDERWRITERS UNDERSTAND THE NATURE OF YOUR RISK:

* ALL QUESTIONS SHOULD BE COMPLETED IN INK.

* WHERE A QUESTION IS NOT APPLICABLE TO YOUR PARTICULAR

CIRCUMSTANCES, PLEASE WRITE ‘N/A’.

* PLEASE TICK THE YES OR NO BOXES.

* IF THERE IS INSUFFICIENT SPACE TO ANSWER QUESTIONS PLEASE

USE AN ADDITIONAL SHEET AND ATTACH IT TO THIS PROPOSAL

FORM.

* COMPLETING AND SIGNING THIS PROPOSAL FORM DOES NOT BIND

THE PROPOSER OR INSURERS TO COMPLETE THIS INSURANCE.

* IF THIS PROPOSAL RELATES TO A NEW BUSINESS OR VENTURE,

PLEASE COMPLETE THE QUESTIONS AS FAR AS POSSIBLE, GIVING

ESTIMATED OR ANTICIPATED INFORMATION.

3

MEDICAL MALPRACTICE/TREATMENT RISK INSURANCE

An Individual or a Partner, Principal or Director of the Firm must complete the proposal form in ink. All

questions must be answered to enable a quotation to be given. The completion and signature of this proposal

form does not bind the Proposer or Insurers to complete a contract of insurance.

If there is insufficient space to answer any question, please continue on your headed notepaper and attach it to

this form.

Please provide any standard contract terms, conditions, agreements or letters of appointment, which you have

with your clients.

PLEASE TYPE OR CLEARLY PRINT YOUR ANSWERS TO ASSIST

UNDERWRITERS’ CONSIDERATION OF THE PROPOSAL

1a) Name of Individual, Institution or Company(ies) (including any subsidiary requiring cover):

b) Date established:

c) Address(es) (specifying who is responsible, if there is more than one location):

d) Website: e-mail address:

e) Name(s) of any previous Company(ies)/Institution(s) requiring cover and the date(s) on which

they ceased trading:

2a) Name of Individual,

Partner, Principal

or Director

Age and

Qualifications

Date Qualified

Number of years

Practical Experience

in this capacity

4

PLEASE ATTACH DETAILED C.V.’S, IF NO RELEVANT QUALIFICATIONS ARE HELD

b) How long has the company/institution been trading under the present management?

c) Names of Consultants

or Self-employed

Sub-Contractors

(under a contract to

provide services)

Age and Qualifications

Date

Qualified

Number of years

experience

(in this capacity)

PLEASE ATTACH DETAILED C.V.’S, IF NO RELEVANT QUALIFICATIONS ARE HELD

d) Do you require cover for past Partners, Principals or Directors?

If yes, please provide details

YES/NO

3a) Is the Individual, Institution(s) or Company(ies) licenced and registered in accordance with the applicable

regulatory body, or in law, to practice the procedures for which cover is sought? YES/NO

If no, please give details.

b) Is the Individual, Institution(s) or Company(ies) a member of any Association or Professional Body or

registered by a self-regulating Organisation? YES/NO

If yes, please give details.

5

c) Has membership of or registration with such ever been suspended, withdrawn, amended, declined or

had conditions attached? YES/NO

If yes, please give details

d) Have you or has any person in the Institution(s) or Company(ies) been the subject of criminal or

disciplinary proceedings or inquiries by any professional or regulatory body? YES/NO


4 Please state the total number of:

Partners, Principals or Directors:

Qualified Medical Staff:

Qualified Nursing Staff:

Nurse Anaesthetists:

Paramedics:

Auxiliaries:

Others (including Admin.):

5a) If you are a sole practitioner, please give details of arrangements made in the event of sickness or holiday.

b) Is this a Part-time occupation? YES/NO

If yes, please give brief details of your present full-time work.

c) Are you self-employed? YES/NO

If no, by whom are you employed and describe your role

6

6 Do you or any employee, involved in patientcare or treatment, suffer from any disability or impediment

which could affect your/their professional duties or place the patients at risk? YES/NO


7 This form is designed for one of the following types of activity. Please answer the questions below,

concerning your activities and then turn to the relevant further questions that follow:

Individual Practitioner YES/NO

Day Care Centre YES/NO

Clinic YES/NO

(with or without Surgical Facilities)

Institution with Overnight Stay YES/NO

Facilities

Ambulance Service YES/NO

Blood, Eye or Sperm Bank YES/NO

Pathology Laboratory YES/NO

Other Activities (please specify) YES/NO

NOW TURN TO THE QUESTIONS RELEVANT TO YOUR ACTIVITIES

7

INDIVIDUAL PRACTITIONER (MEDICAL DOCTOR)

8 Please state the approximate percentage undertaken of the following:

Anaesthesiology

Cardiology

Community Medicine

Dentistry

Dermatology

Endocrinology

General Practice

Genetics

Haematology

Immunology

Industrial Health

Neurology

Nuclear Medicine

Nutrition

Obstetrics/Gynaecology

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

Ophthalmology

Orthopaedics

Orthodontics

Otorhinolaryngology

Paediatrics

Pathology

Pharmocology

Psychiatry

Physiology

Radiotherapy

Rehabilitation

Surgery

Tropical Medicine

Venereology

Any Other Work

(please specify)

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

9 Do you or have you specialised in any of the following surgical areas?:

Cardiac YES/NO

Elective Cosmetic (including YES/NO

Trichology)

Emergency/Casualty YES/NO

Eye Laser YES/NO

Gender Re-assignment YES/NO

Keyhole YES/NO

Organ Transplant YES/NO

Other Major YES/NO

(provide details)

8

INDIVIDUAL PRACTITIONER (SUPPLEMENTARY MEDICINE)

10 Please state whether you undertake any of the following activities:

Audiologist YES/NO

Chiropodist/Podiatrist YES/NO

Chiropractor YES/NO

Dietician YES/NO

Domiciliary Care YES/NO

First Aider YES/NO

Medical Lab Technician YES/NO

Midwife YES/NO

Nurse YES/NO

Nurse Anaesthetist YES/NO

Occupational Therapist YES/NO

Optometrist/Optician YES/NO

Osteopath YES/NO

Pharmacist YES/NO

Physiotherapist YES/NO

Prosthetist/Orthotist YES/NO

Radiograher YES/NO

Speech Therapist YES/NO

Other Activity YES/NO

(please specify)

INDIVIDUAL PRACTITIONER (ALTERNATIVE MEDICINE)

11 Please state whether you undertake any of the following activities:

Acupuncture YES/NO

Acupressure YES/NO

Aerobics YES/NO

Allergy Testing YES/NO

Aromatherapy YES/NO

Biochemistry YES/NO

Biomagnetic Technique YES/NO

Herbalism YES/NO

Homeopathy YES/NO

Hypnosis YES/NO

Kinesiology YES/NO

Lymphatic Drainage YES/NO

Massage YES/NO

Megavitamin Therapy YES/NO

Naturopathy YES/NO

Pilates YES/NO

Radionics YES/NO

Reflexology YES/NO

Shiatsu YES/NO

Sports Massage YES/NO

Stress Control YES/NO

Yoga YES/NO

Other Activity YES/NO

(please specify)

9

12 Please give an approximate percentage of your activities between the following:

Your Own Private Practice

Public Sector Institution

Private Surgical Institution

Private Non-surgical Institution

Patients Own Home

Other (give details)

%

%

%

%

%

%

INSTITUTIONS (WITH OR WITHOUT OVERNIGHT STAY FACILITIES)

13 Please state the approximate percentage undertaken of the following:

Accident & Emergency

Addiction Treatment

Ambulance Service

Blood, Eye or Sperm Storage

Brain Injury Rehabilitation

Clinical Trials

Communicable Diseases

Cosmetic Surgery - Invasive

Cosmetic - Non-surgical

Day Care/Learning Difficulties

Dental

Family Planning/Antenatal

Fertility

General Nursing

Geriatric

Health & Fitness/Dietary

Hospice

Hyperbaric

Learning Disabilities

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

Medical

Mental

Obstetrics/Maternity

Occupational Health

Optometry/Optician

Out of Hours Primary Care

Paedriatrics

Pathology

Pharmacy

Prostheses (including spectacles,

contact lens and hearing aids)

Radiography

Surgical - Keyhole

Surgical - Laser or Refractive Eye

Surgical - Major

Surgical - Minor

Tubercular

Venereal

Other

(please specify)

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

10

14a) How many in-patients were treated during the past three years:

20 20 20

b) Please state total number of: Licensed Beds in Use: Average Daily Occupancy:

Acute Care

Acute Psychiatric

Brain Injury Rehabilitation

Addiction

Elderly Care

Hospice/Palliative

ICU/ITU

Learning Disabilities

Nursing

Psychiatric

Other (please specify

Post-natal/Paediatrics Bassinets/Cribs/Cots in Use: Average Daily Occupancy:

c) Have you treated any patients that live in the USA or Canada (or any of its protectorates)?

YES/NO

If yes, please give any details of any matter that did or could lead to a complaint.

11

15a) How many Operating Theatres do you use on a regular basis?

b) Please detail the average number of surgeries undertaken, in the following categories:

Inpatient: Outpatient:

c) Do you employ surgeons, anaesthetists and nurses? YES/NO


d) Do independent medical staff contract to use your facilities YES/NO


16 Do you have I.C.U. or I.T.U. facilities? YES/NO


17a) If you operate an ambulance facility, please give number of: ambulances:

aircraft:

waterborne craft:

other vehicles:

(please specify to what use these are put)

b) How many calls have you answered during the past three years?

20 20 20

c) Please give details of the treatment your ambulance crews, or paramedics, provide to patients:

d) What training is undertaken by those ambulance crews/paramedics allowed to administer treatment?

e) Do you ever become involved in medical repatriation? YES/NO


12

18a) Do you use C.A.T., M.R.I. or similar Scanners? YES/NO

If yes, please state number used, on regular basis.

b) Do you operate X-Ray machines, for diagnosis, or treatment? YES/NO

Please clarify their use.

c) Do you undertake treatment using radiotherapy equipment? YES/NO

19a) If you have blood, eye or sperm storage facilities or provide a service, please state the average monthly

number of patients, who have used this facility, during the past three years.

b) Please describe how you obtain these donations.

c) How and where are these donations stored?

d) Describe how do you ensure that they are fit for use, by future patients?

13

20a) Do you operate any of the following Out-patient Clinics:

Addiction

Ante-natal

Dental

Elective Cosmetic

Surgery

Elective Tricological

Surgery

Home Health

HIV/Hepatitis

Laser Eye Surgery

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

Nutrition/Diet

Sexually Transmitted

Diseases

Physical Therapy

Psychiatry

Rehabilitation

Sports Injury

Well Man/Woman

Other

(please specify)

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

YES/NO

b) Do you enter into contracts, with Professional sports clubs or organisations, to provide treatment to

elite sports men or women YES/NO


c) Please state the number of out-patients treated during the past three years:

20 20 2 0

d) Have you treated any patients that live in the USA or Canada (or any of its protectorates)?

YES/NO

If yes, please give any details of any matter that did or could lead to a complaint.

21a) Do you provide any counselling services? YES/NO

b) If yes, by whom are these provided?

c) If these counsellors are self-employed, do you ensure that they maintain their own Medical

Malpractice insurance? YES/NO

If no, please explain

14

22 If you operate a pathology service, please state the number of samples/specimens processed in the past

three years:

20 20 20

23a) Please state the gross income received for each of the last three financial years billed to clients and

an estimate for the next twelve months.

Year U.K. Worldwide ex USA/Canada USA/Canada

20 Fees

20 Fees

20 Fees

Estimate

20 Fees

Financial Year ends: (Month)

b) What percentage of income is paid to consultants? %

c) What percentage of income is derived from the sale of products? %

24a) Have there been any major changes in the activities undertaken during the past twelve months or are

any likely to take place in the next twelve months? YES/NO


b) Is cover required for any activity, now ceased, which is different from those declared, within this

proposal form? YES/NO


c) Have you carried out any activities other than those disclosed in this Proposal? YES/NO


15

25 Give by approximate percentage how your practice/institution is funded by:

a) Government/Public %

b) Private %

c) Charitable Donations %

26 Please state from which sectors you derive your patients:

a) NHS %

b) Private %

c) Charitable %

27 Please show the numbers of each of the following job roles:

Registered Nurses:

Paramedics:

Pharmacists:

Residential Medical Officers:

Laboratory Technicians:

Medical Technicians:

Complementary Professionals:

Supplementary Professionals:

Auxiliaries:

Social Workers:

28 Please provide an example of a patient record and state how long these are kept, and where and how they

are stored.

AS THERE IS A SEVEN YEAR STATUTE OF LIMITATIONS, IT IS A CONDITION OF THIS COVER

THAT ALL RECORDS ARE KEPT A MINIMUM OF SEVEN YEARS AND THOSE FOR MINORS,

SEVEN YEARS FROM THE AGE OF REACHING THEIR MAJORITY/ADULTHOOD

16

29a) Do you participate in any teaching programme or have affiliation(s) with educational institutions?

YES/NO

If yes, please provide full details

b) Do you provide any training or teaching facilities? YES/NO

If yes, provide full details

30 Is written informed consent obtained from all, patients, PRIOR to treatment? YES/NO

If no, please explain.

31a) Do you have a risk management programme in place? YES/NO

If yes, what staff training is undertaken, to ensure that they adhere to this criteria?

b) How often are working procedures reviewed, to ensure their continuing suitability and what form do

those reviews take?

32a) Do you provide facilities for the sterlization of instruments, in accordance with current healthcare

guidelines YES/NO

If no, please explain fully

b) Do you employ procedures that ensure that cross-infection is avoided? YES/NO


c) Do you have a written protocol for needlestick injuries? YES/NO


17

33a) Do you ensure that all professionally-qualified healthcare staff, locums or consultants are registered

with and are subscribing members to a medical institute or other professional body? YES/NO

If no, please explain.

b) Do you ensure that all references and qualifications are checked and that CRB checks are undertaken, on

ALL staff (whether part-time, temporary or contract) and that only competent and adequately trained

staff are employed, and that all staff are properly supervised YES/NO


c) Do you ensure that such person or firm maintains in force, annually, their own Medical Malpractice

insurance? YES/NO


34a) Are you licensed, in accordance with the Care Standards Act 2000, and are your registered

with the Care Quality Commission (or equivalent body)? YES/NO

b) Has your registration with the Care Quality Commission, ever been:

i) subject to approved conditions YES/NO

ii) cancelled YES/NO

iii) varied YES/NO

iv) other (please specify) YES/NO

If yes, please explain

c) Have you been in dispute with or been investigated by the Care Quality Commission (or equivalent

body), regarding an a Assessment/Inspection Report? YES/NO


d) Do you have any outstanding recommendations or requirements, from your last Care Quality

Commission Investigation Report? YES/NO


18

35a) Do you operate, wholly or in part, as an NHS Independent Treatment Centre or undertake any work

for the NHS, where liability is covered by the Clinical Negligence Scheme for Trusts or the NHS

Litigation Authority Scheme? YES/NO


b) Do you enter into contract of service agreements, with Primary Care Trusts (or others), which require

them to maintain Medical Malpractice insurance? YES/NO

36a) If you are a member of a consortium or have entered into a joint-venture agreement, please give details.

b) Do you undertake work for or are you associated, either by shareholding or official position, with any

company/organisation/institution, where you are in a position to make major decisions?

YES/NO


c) Have any of the Partners, Principals, Directors or Employees been a Partner, Principal or Director or been

associated with any business that has ceased trading, either voluntarily or compulsorily?

YES/NO


d) Has the company or institution purchased, merged or consolidated with any other company or institution

or sold or demerged from a relationship with another company or institution, in the past five years

YES/NO


e) Is there any intention of purchasing, merging or consolidating with any other company or institution or

selling or demerging from a relationship with another company or institution, in the next twelve months?

YES/NO


19

37 Do you currently have Medical Malpractice insurance? YES/NO


Expiry Date:

Limit:

Excess:

Insurer:

38 Have you ever had any Medical Malpractice insurance cancelled, declined or only written at special terms?

YES/NO


39 Please state: limit of indemnity required:

self insured excess:

40a) Do you always require satisfactory written references when engaging employees? YES/NO

b) Is any Partner, Principal, Director or Employee allowed to sign cheques on their sole signature?

YES/NO


c) How often are employees who receive cash or cheques, during the course of their duties, required to pay

these in?

d How often are checks carried out on all entries in cash books, with all paying-in books, receipts,

counterfoils and vouchers being reconciled with bank statements, including the balance of cash and

unpresented cheques, independently of employees receiving or banking monies, belonging to the Firm

or in trust, on behalf of others?

20

41a) Have you EVER had any claims made against you or know of any circumstances that could or would

have resulted in a claim, if cover had been in force? YES/NO

If yes, please give full details.

b) Have you EVER had been the subject of any investigation, examination, inquiry or other proceeding,

coroner's inquest, prosecution or disciplinary proceedings or have any claims been made against you

or do you know of any circumstances that could or would result from the aforementioned?

YES/NO

If yes, please give full details.

21

IMPORTANT NOTICE CONCERNING DISCLOSURE

It is your duty to disclose all material facts to Insurers. A material fact is one, which may influence an

Underwriter’s judgement in the consideration of your proposal. If your proposal is a renewal, it is likely that

any change in facts previously advised to Insurers will be material and such changes should be highlighted. If

you are in any doubt as whether a fact is material or not, you should disclose it.

FAILURE TO DISCLOSE could prejudice your rights to recover in the event of a claim or allow Insurers to

void the policy.

I/We declare that the statements and particulars contained in the proposal are true and that I/we have not

misstated or suppressed any material facts. I/We agree that this proposal, together with any other information

supplied by me/us shall form the basis of any contract of insurance effected.. I/We undertake to inform Insurers

of any material alteration to these facts occurring before completion of the contract of insurance.

However, the duty to disclose material facts continues after completion of this proposal and throughout any

period of insurance (and any extensions thereto), upon which this proposal form was used as the basis of the

contract of insurance.

Date (day) (month) (year)

Signature: …………………………………… (Individual, Partner, Principal or Director)

Position: ..…………………………………..

A COPY OF THIS PROPOSAL SHOULD BE RETAINED BY YOU FOR YOUR OWN RECORDS

PROFESSIONAL INDEMNITY INSRUANCE - smu.uk.comsmu.uk.com/files/smu_downloads/Proposals/MedMal_2014.pdf · Gender Re-assignment YES/NO Keyhole YES/NO Organ Transplant YES/NO Other Major

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