THE HOLLARD INSURANCE COMPANY LIMITED GENERAL PRACTITIONERS MEDICAL MALPRACTICE PROPOSAL FORM Please ensure that you complete this form fully to enable us to provide you with an accurate and speedy quotation. The truth of the statements made in this form and any other documentation you may provide to us will be incorporated within your policy should our terms be accepted. The completion of this form does not bind YOU or US to any contractual arrangement unless you accept our terms for the issuing of an insurance policy. From the date that you sign this proposal any change in risk or any claims or circumstances that may give rise to claims against you at a later date, must be declared to us. This applies whether or not the completion of this proposal is for a new policy or renewal of an existing policy. Existing insurances with us and generally with other Insurers will lapse at midnight on the last day of your expiring policy. Any extensions of cover or requests to hold covered must be received and agreed by this office prior to the expiry of the current policy. Policies are written on a “Claims Made” basis which means that; a) Indemnity provided is in respect of claims made against you or you becoming aware of circumstances occurring that could lead to claims being made against you during the currency of the policy. b) Policies have a “Retroactive Date” which excludes claims emanating from work undertaken prior to this date. c) Provided there has been no gap in cover we will allow the “Retroactive Date” to remain unchanged on any new policy issued by us.
1. NAME OF PRACTICE(S) ……………………………………………………………………………………………………………………………………. 2.
NAMES AND QUALIFICATIONS OF PARTNERS
Name
Qualification
Name
Qualification
3. POSTAL ADDRESS: ……………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… 4.
PHYSICAL ADDRESS: …………………………………………………………………………………………………….................................. …………………………………………………………………………………………………….................................. …………………………………………………………………………………………………….................................
5. Tel No. (……….) …………………………………………… Facsimile) No. (………)……………………….. E-Mail Address: …………………………………………………………………………………………………………………………………. Contact Person: ………………………………………………………………………………………………………………………………….
6. How long have you been in practice? Current practice: ……… years/months.
Total years in practice:………………….
7. List all professional organizations or registered self-regulating body of which you are a member: …………………………………………………………………………………………………….................................. 8.
Please list your registered qualifications and name the medical school you attended: ……………………………………………………………………………………………………................................ ……………………………………………………………………………………………………...................................
9. List any particular branch of medicine in which you specialize: …………………………………………………………………………………………………….................................... ……………………………………………………………………………………………………..................................... 10. Please state your registered post graduate qualifications and state where they were obtained: …………………………………………………………………………………………………….................................... …………………………………………………………………………………………………….....................................
11. State whether you practice as a: (answer YES or NO for each specialist): a)
Physician
…………………...
b)
Pathologist
…………………...
c)
Oncologist
…………………...
d)
Cardiologist
…………………...
e)
Psychiatrist
…………………...
f)
Radiologist or Roentenologist
…………………...
g)
General Surgeon
…………………...
h)
Plastic Surgeon
…………………...
i)
Orthopaedic Surgeon
…………………...
j)
Urologist
…………………...
l)
Thoracic Surgeon
…………………...
m)
Neuro Surgeon
…………………...
n)
Cardio Vascular Surgeon
…………………...
o)
Otorhinolaryngologist
…………………...
p)
Proctologist
…………………...
q)
Ophthalmologic Surgeon
…………………...
r)
Ophthalmologic Physician (excluding surgery)
…………………...
s)
Obstetrician & Gynaecologist
…………………...
t)
Physician and non-specialist surgeon
…………………...
u)
Other Practitioner (Describe fully)
…………………...
……………………………………………………………………………………………………...................................... ……………………………………………………………………………………………………......................................
12. State approximate division of your work and indicate if you require coverage for the following: Work a) The prescription or fitting of Contact Lenses
Percentage of Total work ……………%
b) Hypnosis
……………%
c)
……………%
The treatment of mental illness, drug addiction or alcoholism
d) i)
Diagnostic X-Ray procedures (other than plain X-Ray)
……………%
ii)
Angiographic procedures and Cardiac Catheterization
……………%
iii) Administration of spinal, caudal, epidural or general anesthesia e) Plastic Surgery (other than minor skin grafts)
f)
……………% ……………%
i)
Traumatic
……………%
ii)
Cosmetic
……………%
Major Surgery, which shall be defined as: i)
Orthopaedic Surgery (other than orthopaedic operations on the
……………%
smaller joints) ii)
Neuro-Surgery
……………%
iii) Amputation of Limbs
……………%
iv) Plating, pinning open reduction of fractures
……………%
v)
……………%
Procedures involving entry surgically or otherwise into the spine, thorax or skull
vi) Procedures involving entry surgically or otherwise in the abdomen (other than procedures concerned with Normal delivery which may include episiotomy and application of low forceps).
……………%
vii) Mastectomy
……………%
g)
viii) Resection of facila bones and tissssues
……………%
ix) Operations on the organs of th e neck (other than biopsy excision of lymph nodes)
……………%
x)
Reconstructive vascular surger y and thromboembolectomy of the larger arteries and veins
……………%
xi)
Ophthalmic Surgery
……………%
xii) Mastoidectomy
……………%
xiii) Operations on the inner ear
……………%
xiv) Esophagoscopy
……………%
xv) Exchange Transfusions
……………%
Intermediate Surgery which shall be defined as i)
Tonsillectomy
……………%
ii)
Adenoidectomy
……………%
iii)
Closed reduction of fractures
……………%
iv)
Surgical or injection treatment of varicose veins
……………%
v)
Orthopaedic operations on the smaller joints
……………%
vi)
Amputation of digits
……………%
vii) Dilation and curettage
……………%
viii) Culdoscopy
……………%
ix)
Cystoscopy
……………%
x)
Gastroscopy
……………%
xi)
Sigmoidoscopy
……………%
xii) Bronchoscopy
……………%
xiii) Biopsy excision of lymph nodes
……………%
xiv) Circumcision
……………%
h) General Practice which in no circumstances include any of the
……………%
procedures in 12 (g) above i) Any other procedure (please describe)
……………%
……………………………………………………………………………………………………................................. ......... ……………………………………………………………………………………………………................................. .......... 13.
If any of the work carried out under point 12 above is at a State Facility, kindly indicate the percentage of state work carried out for the categories listed above: ……………………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………..
14.
Have you or any of your Partners, Assistants, Technicians or Nurses any physical, physiological, pathologic or psychiatric disability?……………………....................................... If YES, please give details: ……………………………………………………………………………………………………....................................
15. Are you in the employ of any individual, firm or group (other than that referred to above), hospital or any category of health facility of any kind?…………………….................. If YES, please give details: …………………………………………………………………………………………………….................................... …………………………………………………………………………………………………….................................... 16. Are you under contract to any individual, firm or group, hospital (of any category) or health facility of any kind? …………………….......................................................................... ……………………………………………………………………………………………………....................................
17. Are you engaged in any additional medical activities for which you receive payment? If YES, please give details: …………………………………………………………………………………………………….................................... …………………………………………………………………………………………………….....................................
18. Do you own, wholly or in part, or operate, or administer any hospital, nursing home or other institution where medical services are rendered?………………….. If YES, please give details: ……………………………………………………………………………………………………..................................... …………………………………………………………………………………………………….................................... 19.
Do you ever employ Locums to assist you at your practice
Yes
No
If yes, kindly ensure that all Locums have their own Professional Indemnity / Medical Malpractice Policy in place, as their activities will not be covered in terms of your Policy. 20.
Have you ever been convicted for an act committed in violation of any law or ordinance other than traffic offences? …………………….......... If YES, please give details: …………………………………………………………………………………………………….................................... ……………………………………………………………………………………………………....................................
21.
Have you ever been the subject of disciplinary proceedings or reprimand by an administrative body or a professional association? …………………….................................. If YES, please give details: …………………………………………………………………………………………………….................................... ……………………………………………………………………………………………………....................................
22.
Fee Income (This question must be completed accurately as the figures are used for rating purposes). When is your Financial Year End: ……………………............................................ What are your estimated fees for the coming 12 months: From Private Practice: ……………………………………………………. From State Institutions: …………………………………………………. Please give gross fees (excluding VAT) received for the past three completed financial years:
23.
Financial Year:
Gross Fees:
………………
R …………………
………………
R …………………
………………
R …………………
Claims Have any claims of professional negligence, error or omission ever been made against the Practice or any of the present or past Principals, whether insured or not. If yes, please give full details: …………………………………………………………………………………………………….................................... ……………………………………………………………………………………………………....................................
24.
Are any of the Principals or Employees of the Practice, after enquiry, aware of any circumstances that may give rise to a claim for professional negligence, error or omissions? If YES, provide reasons why: …………………………………………………………………………………………………….................................... ……………………………………………………………………………………………………....................................
25.
Has any application for insurance of this nature (made on behalf of the Practice or their predecessors in business or by any of the present Partners) ever been declined, cancelled or has renewal been refused or have special terms been imposed? If YES, please give full details: …………………………………………………………………………………………………….................................... ……………………………………………………………………………………………………....................................
26.
Is the Practice currently insured for Professional Indemnity Insurance? ……………………….. If YES, please complete the following (applicants who are not currently Hollard Clients, should attach a copy of the Schedule page of their current insurance policy as we can verify the retroactive cover date):
27.
Do your partners carry their own malpractice insurance? If so, state with whom. ……………………………………………………………………………………………………....................................
28.
Quotations required: Limits of Indemnity: ……………………………………………………………………………………………………… Deductible / First Amount Payable* : …………………………………………………………………………… * This may vary from what insurers are prepared to consider.
28.
Retroactive Cover: Do you require cover in respect of liability incurred, but not discovered prior to effecting of this insurance, at a single premium to be negotiated. If you are currently insured and there has been no gap in cover then you will automatically be insured for retroactive cover as per your expiring policy. If you are NOT insured we recommend that you consider insuring your prior work: ……………………………………………………………………………………………………...................................
DECLARATION: I/We hereby declare that the statements and particulars in this application are true and complete and that at the present time, other than stated above, I/We have no reason to anticipate any claim being brought against me/us, that might constitute a claim under the insurance now being requested. I/We agree that this Proposal and Deceleration be the basis of the Contract between me/us and the Insurers. DATED
……………………………………………………………………………………………………………………………………………….
SIGNATURE OF PRINCIPAL / PARTNER/ DIRECTOR
…………………………………………………………………………..
NAME OF PRINCIPAL / PARTNER/ DIRECTOR
…………………………………………………………………………
