Medical Malpractice Application

Complete this application form to help us find out more about you. Completion does not oblige either party to enter into a contract of insurance.

General Information

Medical Services

Claims Experience

Indemnity History

Declaration

Section 1: General Information

The purpose of this application form is for us to find out more about you. Please provide all information which may be material to the cover we offer.

Insured name

Contact name

Address

Postcode

Telephone

Email address

Website

Date business was established

Date the business started trading

Please provide details of all trading addresses, including any overseas trading addresses:

Please state whether you have ever carried out any activities under any other name or have been part of a merger or de-merger:

Yes

Please state whether there is any overseas corporate entity or private individual that has or has ever had an interest in or ownership or control of the business:

Yes

Please state whether you are a member of, or registered with, any associations, professional bodies or self-regulatory organisations:

Yes

Please state whether you hold a valid licence, or are registered with an appropriate regulatory body or as otherwise required by law, to practice your business:

Yes

Please state whether you have ever been refused membership of any association, professional body or self-regulating organisation or have had any licence suspended, revoked or had special conditions imposed:

Yes

Please state who is responsible for the Clinical Risk Management in your business:

Name

Position

Date joined

Qualifications