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Medical Indemnity 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.  
 

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Professional Credentials

Specific Risk Elements

Complaints, Adverse Clinical Events, Areas of Concern & Attestation

Payment Details

  • Applicant
  • Credentials
  • Risk
  • Details
  • Payment

Personal Details

First Name

Surname

Maiden / Previous name

Gender

Title

Date of Birth

ID Number

Contact Number

Work Phone

Emergency Number (After hours)

Facsimile

Website

Nationality

Country of Permanent Residence

Address for Correspondence

Address for Principal Office

Qualifications (1 per line)

Date of primary qualification

Practice Details

How long have you been practicing?

Statutory council number

If you are registered as a specialist with the HPCSA or other registration authority in South Africa, please indicate your speciality and all sub-specialities

Specialties

Sub-specialties

PCNS Number

VAT Number (If applicable)

Do you treat patients who are citizens of other countries who have travelled specifically to receive treatment from you? If yes, please provide details on the type of care and the number of patients treated in the past 12months

Has your license ever been withdrawn? If yes, please provide details

Are you a member of any association or professional body, or registered with any self-regulating organization? If so, please provide details of that body and your registration number

Has your membership or registration with such organisation ever been declined, withdrawn, suspended, or had conditions imposed? If yes, please provide details

Professional Credentials

Doing alcohol and drug rehabilitation?

Please list all your medical qualifications and the month/year in which they were awarded

What is your practice status in the current year?

How is your time spent in your professional capacity?

How many hours a week do you spend in private practice?

How many private patient do you consult per week?

How many hours per week do you spend:

Providing services in a private trauma/casuality unit?

Performing locum work?

Repatriating patients?

Doing medico-legal consulting?

Conducting / participating clinical trials?

Specific Risk Elements

Do you, the insured, have any medical malpractice or professional indemnity?

If yes, please state name of insurer, renewal date, limit of indemnity, retroactive date & excess

Have you had any break in clinical practice over the past 2 years?

Has your professional status changed in the last 12 months?

Has your professional role / job changed in the last 12 months?

Has any Indemnity provider, in respect of the risks to which this application relates, ever:

a) declined an application, refused renewal or withdrawn cover due to a complaint / adverse clinical outcome?

b) required an increased premium or imposed special conditions?

c) declined an indemnity / insurance claim by the Insured or reduced its liability to pay an insurance claim in full (other than by application of an excess)?

Has any claim been made against you in respect of the risks to which this application relates?

Have you incurred any other loss or expense which might be within the scope of your professional practice?

INVASIVE PROCEDURES:

Please share with us the average number of procedures you perform each week in each of the categories below:

Needle biopsy

Dry needling

Intra-articular injection

Endoscopy

ANAESTHESIA:

Please share with us the average number of procedures you perform each week in each of the categories below:

Conscious sedation

Localised anaesthesia

General anaesthesia

IMAGING:

Please share with us the average number of procedures you perform each week in each of the categories below:

Obstetric ultrasound

X-ray

DELIVERIES:

Please share with us the average number of procedures you perform each week in each of the categories below:

Last Year

This Year

PRIVATE OBSTETRIC SERVICES:

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:

% time providing these services per week

Avg. no of patients per week

PRIVATE AESTHETIC/COSMETIC PROCEDURES:

Please share with us the average number of procedures you perform each week in each of the categories below:

Botox

Chemical peels incl. superficial peels

Facial sclerotherapy

Hair transplants

Microdermabrasion

Non-permanent dermal fillers

Sclerotherapy

Surgical procedures

Tattoo removal

PRIVATE REFRACTILE LASER SURGERY:

Please share with us the average number of procedures you perform each week in each of the categories below:

Last Year

This Year

TERMINATION OF PREGNANCY:

Please share with us the average number of procedures you perform each week in each of the categories below:

Last Year

This Year

VASECTOMY:

Please share with us the average number of procedures you perform each week in each of the categories below:

Last Year

This Year

Details

Kindly provide details on all relevant certifications, qualifications achieved in performing the above procedures.

Do you currently perform services in Accident and Emergency units?

Details of complaints, adverse clinical events & areas of concern

Have you ever received a complaint arising out of your professional practice?

Have you ever been involved in any disciplinary inquiry by your employer / council for medical schemes, individual medical scheme?

Have you ever had private practice privileges refused/withdrawn/made conditional by any registration body, association, hospital or other health care provider?

Have you ever had conditions imposed on your practice, been suspended or removed from a medical register due to a complaint, inquiry or investigation?

If yes to any of the above

Please state the following on each reportable instance: - Description of complaint/disciplinary inquiry - Date and details - How it was resolved including settlement details, what recurrence prevention steps have been put in place to prevent the situation that gave rise to the complaint

Please provide detail:

Attestation

I am NOT aware of request for records from a patient, family member of a patient, or attorney

I am NOT aware of a letter from an attorney regarding my treatment of a patient

I am NOT aware of a patient, family member of a patient, or a patient representative’s dissatisfaction with the outcome of a procedure, treatment, diagnosis or fee

I am NOT aware of any circumstances that might reasonably lead to a claim or suit, even if the claim or suit is without merit

I am not aware of any complaint, investigation or disciplinary action taken against me with any regulatory body, hospital committee, peer review committee, the Health Professionals Council of South Africa, or any other government or regulatory entity during the 3 years prior to the proposed effective date of this policy

I have NEVER been charged or convicted of any criminal offence

I have NEVER had any hospital privileges restricted, suspended, whether voluntarily or involuntarily, and I am not currently under investigation with any hospital

I have NEVER practiced medicine without medical professional liability coverage in force

I have NEVER had medical professional liability insurance

My license to practice medicine and license to dispense drugs and medication has NEVER been revoked or limited

I do NOT perform major surgical procedures in an office-based setting (procedures performed under general, spinal, or caudal anaesthesia)

I do NOT perform any procedures that are outside the customary scope of practice for which I am applying for coverage

I do NOT perform any of the following aesthetic procedures: Botox Injection, Chemical Peel, Cosmetic Tattooing, Laser Hair Removal, Laser Wrinkle Removal, Microdermabrasion, Permanent Makeup Sclerotherapy Smart Lipo, fillers

If any information supplied on this application changes between the application date and the effective date of insurance, I will immediately notify CICL of such changes and CICL may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. I understand that my failure to notify CICL of any changes may be grounds for cancellation of the policy Smart Lipo, fillers

I confirm that I have read, understood and accept the CICL Policy Wording and all applicable endorsements and or annexures thereto

Please state Rand value limit of indemnity required under this medical malpractice insurance: and or annexures thereto

Payment Details

We have the following payment options available:

Direct Deposit or EFT (Annual, no installments):
Bank: Standard Bank
Branch: Randburg
Branch Code: 01-8005
Account Name: CICL – Ethiqal Premium Account
Account Number: 221 034 552
Account Type: Business Current Account

Bank Guaranteed Cheque:
Crossed and an annual amount made payable to: CICL - EthiQal Premium Account

Debit Order:
Charged to your bank account on the next available month end either:
- Annually (payable on last working day of the first month at the beginning of year)
- Quarterly (4 equal installments each payable at the beginning of each calendar quarter)
- Monthly (10 equal installments from February to November)

I wish to pay my premiums via

Declaration

By submitting this application I, the undersigned duly authorised, declare that:

  1. I am authorised to sign this application form;
  2. All of the above statements are correct, true and complete;
  3. No information material to this application form has been withheld;
  4. I have read the important facts which you have put before me;
  5. I understand the advice given in relation to the duty of disclosure;
  6. I have made all necessary enquiries in order to comply with the duty of disclosure;
  7. I understand that no insurance is in force until such time as the insurer has confirmed acceptance of the proposed insurance;
  8. I undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance;
  9. 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;
  10. 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;
  11. 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.