15 1. i) Title, Name(s) & Surname of the Insured: (Individual) (If Company/cc/partnership see Trading Name)
ii) Identity Number: iii) Vat No:
2. i) Trading Name (if company/partnership/cc/organization): ii) Company VAT Number: iii) Compnay Registration Number: 3. i) HPCSA NUMBER for individual/Company Registration no. If organisation ii) Are you a member of any organisation/ Association/ Society? If so please indicate which one.
iii) Email Address:
4 i) Address: Postal Postal Code: Country: Telephone Number: Cell Number: ii) Practice / Trading address / es (If different from above): Postal Code: Country: Telephone Number:
VEMBER 20 15 6. In what AREA or branches of ALLIED HEALTHCARE medicine are you qualified and, if applicable, licensed to practice? ACUPUNTURE AROMATHERAPIST AUDIOLOGIST/ SPEECH THERAPIST BIOKINENTICIST CHINESE MEDICINE CHIROPRACTICE CYTOLOGIST DENTAL THERAPIST DIETICIAN HOMEOPATHY MEDICAL PHYSICIST MEDICAL TECHNOLOGIST NATUROPATHY NURSE (PRIVATE HOSPITAL EMPLOYED) NURSE (PRIVATE PRACTITIONER)
NURSE (STATE HOSPITAL EMPLOYED) NURSE IN PATH LAB/ WOUNDCARE ONLY OCCUPATIONAL THERAPIST OPTOMETRIST ORAL HYGIENIST / DENTAL THERAPY 5. i) WHAT IS YOUR TOTAL GROSS ANNUAL INCOME EXCLUDING INCOME FROM THE SALE OF GOODS? (If new business please state estimated income for the forthcoming 12 months.)
THIS QUESTION MUST BE ANSWERED
ii) Do you undertake any work for the state? If so, kindly indicate turnover derived.
15 ORTHOTIST / PROSTHETIST OSTEOPATHY PARAMEDICS/ MEDICS AMBULANCE OPERATOR PODIATRIST PSYCHOLOGIST (Clinical/Other) RADIOGRAPHER REFLEXOLOGIST SEXOLOGIST SPORTS SCIENTIST
Other (Please specify):
Please provide full details of all qualifications and courses that you have undertaken, on the above branches of Medicine. (Please provide a separate sheet)
7. Please give full details of what patient records are kept, where and how they stored and how long are they retained:
8. If employee, please state the name of the company (or other entity) for whom you work:
IF THE ANSWER IS ‘YES’ AN ADDITIONAL PROPOSAL FORM WILL HAVE TO BE COMPLETED BEFORE QUOTATIONS CAN BE GIVEN
9. Do you own (wholly or partly), operate or administer any hospital, nursing home or any other medical establishment? YES NO 10. i) Does any person involved in treatment and care of any patient suffer from any disability, transmittable diseases i.e. Hepatitis, H. I. V. etc or other impediment which may affect the performance of his / her professional duties or place patients / clients at risk? YES NO
VEMBER 20
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ii.) Has the Proposer or any employee involved in the treatment or care of patients been the subject of or convicted of any criminal offence (other than minor traffic offences), professional disciplinary proceedings or inquiries?
YES NO If ‘YES’ please give full details: (on a separate sheet)
11. IF you are an employee, is it a condition of your employment that you maintain Medical Professional Liability Insurance? YES NO
12. Have you ever been Insured for Professional Indemnity? YES NO If ‘YES’ please state:
The name of the Insurer / s:
The Insurance period:
The limits of indemnity provided:
13. Has any application for this type of Insurance cover been?
a.) Declined? YES NO
b.) Cancelled? YES NO
c.) Required special terms YES NO If ‘YES’ please give full details (On a separate sheet):
14. Please complete for each member of staff to be covered on a separate sheet: (Sole Practitioner n/a for not applicable)
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PREVIOUS CLAIMS HISTORY
15. i) List all claims made against the proposer during the last 5 years (on a separate). IF NONE, PLEASE STATE “NONE” Date of Incident | Date of Claim | Amount Claimed | Amount Paid | Amount Outstanding | Details including nature of the allegations and the details of the Claimant. ii.) List all circumstances / complaints, which may give, rise to a claim being made against the Proposer. IF NONE, PLEASE STATE “NONE” Date of Circumstance / Complaint | Details including the nature of the complaint and details of the complainant 16. i) Have all of the above in question 15 been notified to your previous Insurers: YES NO ii.)Have all of the above been accepted by your previous Insurers? YES NO 17. Please indicate what limit of indemnity you require quotations for:
VEMBER 20
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SIGNING OF THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER OR INSURERS TO
COMPLETE A CONTRACT OF INSURANCE
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 Insurers or influence the acceptance of this Proposal and should the above particulars alter in any way I / We will advise the Insurers as soon as possible. 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 Insurers refusing to provide indemnity or voiding the policy in every respect. I / We hereby agree and accept that this declaration shall be the basis of the contract between both parties if entered into. NAME OF PROPOSER: (IN BLOCK CAPITALS) SIGNATURE: DATED:
