Questionnaire & Application Pack. For. Complimentary Medical Malpractice Professional Indemnity Insurance.

Transcription

1 Questionnaire & Application Pack For Complimentary Medical Malpractice Professional Indemnity Insurance. This pack contains the following documents:- Our FSA Keyfacts document explaining who we are. Our FSA Demands & Needs statement. The questionnaire application for insurance. Our request document to correspond by .

2 about our services Registered Offices : LegalRisks.co.uk (LegalRisks.co.uk is a trading style of Sennet Professional Risks Limited) Company registration # Park Street Deal Kent CT14 6AG 1. The Financial Services Authority (FSA) The FSA is the independent watchdog that regulates financial services. It requires us to give you this document. Use this information to decide if our services are right for you 2. Whose product do we offer? We offer products from the whole market We only offer products from a limited number of companies. Ask us for a list of the companies and products we offer We can only offer products from one company We only offer our own products Ask us for a list of companies and products that we offer. 3. Which services will we provide you with? We will advise and make a recommendation for you after we have assessed you needs You will not receive advice or a recommendation from us. We may ask some questions to narrow down the selection of products that we will provide details on. You will then need to make your own choice about how to proceed. We will provide basic advice on a limited range of stakeholder products and in order to do this we will ask some questions about your income, savings and other circumstances but we will not - conduct a full assessment of your needs - offer advice on whether a non stakeholder product may be more suitable 4. What will you have to pay us for our services? Before we provide you with advice, we will give you our keyfacts guide about the costs of our services. We will tell you how we get paid, and the amount, before we carry out any business for you. 5 Who regulates us? LegalRisks.co.uk [LegalRisks.co.uk is a trading style of Sennet Professional Risks Limited] registered offices 11 Park Street, Deal, Kent. CT14 6AG Legalrisks.co.uk is an Appointed Representative of Griffin Insurance Services Limited. FSA number : You can check this on the FSA s Register by visiting the FSA s web site or by calling them on Loans and Ownership Legal Risks [Legal Risks is a trading style of Sennet Professional Risks Limited Is a privately owned limited liability company, limited by shares. 7 What to do if you have a complaint If you wish to register a complaint, please contact us In writing Write to Mr Paul James, Legalrisks.co.uk, 11 Park Street, Deal, Kent. CT14 6AG. By telephone By pauljames@legalrisks.co.uk If you cannot settle your complaint with us, you may be entitled to refer it to the Financial Services Ombudsman, Financial Ombudsman Service,South Quay Plaza,183 Marsh Wall,London E14 9SR Telephone: is procedure will not prejudice your legal rights. 8 Are we covered by the Financial Services Compensation Scheme (FSCS)? We are covered by the FSCS. You may be entitled to compensation from the scheme if we cannot meet our obligations. This depends on the type of business and the circumstances of the claim. Most types of investment business are covered 100% of the first 30,000 and 90% of the next 20,000 so the maximum compensation is 48,000. Insurance advising and arranging is covered for 100% of the first 2,000 and 90% of the remainder of the claim, without any upper limit. For compulsory classes of insurance, insurance advising and arranging is covered for 100% of the claim, without any upper limit.

3 Demands and Needs Statement Legalrisks.co.uk operates a policy of clarity and use of plain English. We act for you as an Insurance Intermediary. We will search the insurance market pertinent to your request for insurance coverage. This means if you ask us for a specific insurance type of insurance (office insurance, business insurance, indemnity insurance etc) we will approach specific underwriters who are experts in those fields. How do we do this? To enable us to search for insurance for you we ask you questions about what insurance you need. The best way we can do this is by asking you to fill in a questionnaire (also known as a Proposal Form or Application Form) which contains a range of questions. Each type of insurance has a different type of questionnaire that is designed to give underwriters the information that they require so that they understand your activities and the amount of risks associated to your work. The questionnaire allows you the opportunity to explain your work and requirements for insurance, the scope of cover and amount, often referred to as the limits of indemnity. Very often a Curriculum Vitae will be requested in addition to this. This information will allow underwriters to offer you terms and conditions for your insurance policy. It is essential that all information contained in these questionnaires is accurate and that no details or information which may effect underwriter s decisions is withheld. Any withholding of pertinent information may allow underwriters to limit or refuse payment of claims. Execution only insurance We will not undertake execution only insurance (placement of insurance by demand of the client in preset form with predetermined underwriters) unless in our opinion this permits the client appropriate insurance provisions. Assessment of Demands and Needs Once we have received your completed questionnaire we can review your request for insurance. Depending on the information you provide us we can assist you with advice on the scope of cover and the amount of insurance you may require. We are dependent upon the information which is provided to us as well as the specific requests as to what advice about insurance you need. Our advice to you will not only depend on the information we require but will take into account your ability to purchase. If you are involved with or undertake work within specific types of work that are governed by Law or Institutes or Associations or Societies we will ensure that your insurance is adequate for purpose relative to these needs. Once we have obtained terms and conditions form underwriters we will confirm these to you by means of a quotation. This document will detail the insurance, it s cost and special clauses (conditions that affect the scope of cover) for the insurance cover. We will issue this quotation based on our reading of the questionnaire and the suitability of the underwriters terms so as to afford you the most appropriate insurance. We recommend that you not only consider the immediate necessity or requirement for professional indemnity insurance but other insurances that may be appropriate to your needs such as Office & Contents and Employers Liability. We can advise you on various forms of insurance which are related and are often purchased as packages and how these best fit your requirements. In certain circumstances we may not be the appropriate intermediary to undertake the effecting of the insurance contract. In these circumstances we will advise you and the options open to you.

4 Client Information Sheet - Your Questionnaire. Proposal forms and Information So that underwriters can fully assess you and your business they require information about your activities. This information is compiled by means of completing a questionnaire or proposal form. In this form you will be asked questions about yourself, your company and its activities. It is imperative that you answer these questions as fully as possible and declare all details that may be pertinent to the future insurance contract. Incorrect answers or withholding of pertinent information could lead to underwriters having the right not to pay claims or repudiating the policy. What sort of information? Underwriters want to know who you are, how much experience you and your company have and exactly what you do. The questionnaire will ask you all of these details. Sometimes it is a good idea to provide additional information. For instance, if a sole trader or two partner practice, provision of CVs is a good way forward. If you have company brochure it is a good idea to supply this. The clearer and fuller the information the better, this will allow us to obtain the most appropriate terms for you. If your company has not started trading then underwriters will require good estimates of what you intend to do and the amount you expect to earn or turnover. If your company provides consultancy or training services then clearly describe what you consult in or what you train people for. If you or your company use standard terms of trade then a copy of these will help underwriters to understand how you work and how you control the work with your clients. If you have any questions about what should be disclosed please contact us for clarification. The questionnaire forms part of the insurance contract, so it is important that all information is clear, factual and that no information that could affect the insurance terms is withheld. As part of the insurance contract the questionnaire must be hand signed and dated by you declaring its accuracy. What happens once the Questionnaire is returned to Legalrisks.co.uk? Once Legalrisks.co.uk has received the questionnaire and any additional information we will approach various underwriters for you so as to obtain the most appropriate scope of insurance for your needs. These terms will be provided to you in the form of a quote. If you have any questions about the terms or conditions of the quote you must ask for clarification. Sometimes underwriters apply conditions or need additional information and you must be aware of these terms. Please ask us what they mean. In certain circumstances you may instruct us to effect insurance that may not be appropriate. In such circumstances we will advise you of the appropriateness and reserve the right to withdraw our services. As your agent we are legally bound to act in your best interest at all times. For further information on what happens during the process of insurance please visit our web site at Please complete the following questionnaire, check all the details, sign and date the document, enclose any accompanying information and return it to us By post to : or By to : Freepost RRXS-STER-CSEG Legalrisks.co.uk 11 Park Street Deal CT14 6AG or By fax to :

5 Complementary Medical Practitioners 1.a Full name of Insured 1.b Trading Name (if different to 1.a) Have you ever engaged in a similar activity under a different name? If please give full details and previous names: 3.a Main Address 3.b Address Telephone Number Facsimile Number 3.c Practice Address (if different from above) Post Code 3.d Telephone Number Facsimile Number Address Post Code 4 Please attach a full Curriculum Vitae that must include details of: Medical School /Establishment you attended and qualified at In which year did you qualify Degree / Qualification obtained Date of birth Details of any post-graduate qualifications / additional qualifications / courses If cover is required for more than one practice address, please provide a full CV for each practitioner including details as above. 5a THIS QUESTION MUST BE ANSWERED. What is your total gross annual income excluding income from the sale of goods? (If new business please state estimated income for the forthcoming twelve months.)

6 5.b Total number of Treatments / Sessions / Consultations? 6 In what branch or branches of complementary medicine are you qualified and, if applicable, licensed to practise? Acupuncture Acupressure Alexander Technique Aromatherapy Ayurveda Bach Flower Remedies Bates Method Biochemics Chiropractic Colonic Irrigation Colour Therapy Counselling Crystal Therapy Craniosacral Therapy Healing / Reiki Herbalism Homeopathy Hypnosis Iridology Kinesiology Light Touch Therapy Massage Moxibustion Music Therapy Multi Vitamin Therapy Naturopathy Nutrition Therapy Osteopathy Polarity Therapy Psychotherapy Radionics Reflexology Rolfing Shiatsu Yoga Other (please specify) 7 Please give full details of what patient records are kept, where and how they are stored and for how long they are retained: Please note that it is a requirement of this policy that all records are retained for a minimum period of ten years, and in the case of minors, ten years from majority. 8.a Please state the approximate percentage breakdown of your work between the following categories and state whether you are employed or self-employed: The Proposers s Private Practice Public Sector Hospitals / Homes Private Surgical Hospitals / Homes Private Non-Surgical Homes Patients Homes Other (please specify) Total Employed Self-Employed

7 8.b If you are an employee, please state the name of the employing authority or the name of the private hospital or company for which you work: 9 Do you own (wholly or in part), operate or administer any hospital, nursing home or any other medical establishment? If the answer is an additional proposal form will have to be completed before quotations can be given Does any person involved in the treatment or care of any patient suffer from any disability, transmittable disease i.e. Hepatitis, H.I.V. etc., or other impediment which may affect the performance of their professional duties or place their patients at risk? If what procedures are in place to protect patients? 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? If please give full details: 12.a Are you a member of any professional organisation, or registered with any self-regulating body? If please state which organisation and the period of membership / registration: 12.b Has membership or registration with any such organisation / body ever been suspended, withdrawn, amended declined or had conditions attached? If please give full details:

8 13 If you are an employee, is it a condition of your employment that you maintain Medical Professional Liability Insurance? If please give details: 14.a Have you ever been Insured for Medical Professional Liability? If please state: i) The name of the Underwriter/s ii) The Insurance period/s iii) The limits of liability provided 14.b Has any application for this type of Insurance cover ever been: i) Declined? ii) Cancelled? iii) Required special terms? If please give full details: 15 Please complete for each member of staff to be covered: Full time / Part-time Branch of Medicine Qualification Date Qualified 16.a List all claims made against the Proposer during the last ten years. If NE please state None : Date of Incident Date of Claim Amout Claimed Amount Paid Amount Outstanding Details including nature of the allegations and details of Claimant

9 16.b List all circumstances / complaints that may give rise to a claim being made against the Proposer. If NE, please state None : Date of Circumstance / Complaint Details including nature of the Complaint and details of the Complaint 17.a Have all of the above in question 16 been notified to your previous Underwriters: 17.b Have all of the above been accepted by your previous Underwriters: 18 Please indicate which limit(s) of indemnity you require quotation for: 250, ,000 1,000,000 2,000,000 Other Please provide full details of your hygiene and cleaning procedures

10 This page forms your declaration to underwriters and can also be used to provide any additional information that you might want to provide pertinent to your Firm that may assist underwriters in their decision making process. In all cases underwriters will require you to sign and date this form. If you present this proposal form to us electronically (by ) you will eventually be required to sign and date this form. I/We declare that the statements and particulars in this proposal are true and that I/We have not mis-stated or suppressed any material facts. I/We agree that this proposal, together with any other information supplied by me/us shall form the basis of any Contract of Insurance effected thereon. I/We undertake to inform insurers of any material alteration to these facts occurring before completion of the Contract of Insurance. Returning this proposal does not bind the Proposer or Underwriter to complete this insurance but does authorise 'Sennet Professional Risks Limited' to seek terms on my/our behalf from Insurers including current Insurers if any. Signed: Date: (this must be signed by a Partner, Director or equivalent ranking employee) All information provided to us and then to underwriters is governed by the DATA PROTECTION ACT Sennet Professional Indemnity Risks and Underwriters act strictly in accordance with the Act its principals and tenets and any subsequent amendments thereto.

11 E Correspondence Agreement Form This is an agreement between :- Name of Client Address : and Legalrisks.co.uk (being a trading style of Sennet Professional Risks Limited Company Registration ) Legalrisks.co.uk requests the Clients agreement to correspond by means of and other electronic forms of communication. Legalrisks.co.uk will keep copies of all E documents and correspondence on a permanent basis and make such available to the client whensoever requested. Legalrisks.co.uk is bound by the Data Protection Act 1998 registration # Z X and will maintain all records pertinent to the client under compliance thereto. We hereby agree to accept electronic correspondence between ourselves and Legalrisks.co.uk as legal documents and an acceptable means of correspondence. Signed For and on behalf or Legalrisks.co.uk Date 09/07/2008 Signed For and on Behalf of the Client Date This document must only be signed by the Principal, a Senior Director or other such person who has the authority or authorisation of the Company to undertake such an agreement.