MEDICAL INDEMNITY APPLICATION FORM
Please complete this application form.
* Kindly note that failure to disclose full and accurate details of any fact or circumstance that is relevant or may be considered relevant to the insurer’s decision to extend cover to you, may result in the rejection of any claim or the cancellation of this insurance contract.
Specific Risk Elements
* Please share with us the average number of procedures you perform each week in each of the categories below:
INCLUDING ULTRASOUND BEYOND ANTE-NATAL CARE AFTER 24 WEEKS GESTATION
Details of complaints, adverse clinical events & areas of concern
I, the undersigned duly authorised, declare that:
- (i) I am authorised to sign this application form;
- (ii) All of the above statements are correct, true and complete;
- (iii) No information material to this application form has been withheld;
- (iv) I have read the important facts which you have put before me;
- (v) I understand the advice given in relation to the duty of disclosure;
- (vi) I have made all necessary enquiries in order to comply with the duty of disclosure;
- (vii) I understand that no insurance is in force until such time as the insurer has confirmed acceptance of the proposed insurance;
- (viii) I undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance;
- (ix) I acknowledge that the insurer relies on the information and representations in this application form and otherwise made by me in relation to this insurance;
- (x) except where indicated to the contrary, I understand that any statement made in this application form will be treated by the insurer as a statement made by all persons to be insured;
- (xi) I have read CICL Insurance’s Privacy Statement on this application form, and consent to the use, disclosure and obtaining of personal information about the Insured for the purposes shown in the Privacy Statement.