Medical Malpractice Insurance Proposal Form Kerry London agency ref 2318 General information Company and/or Individual name: Hille House 132 St Albans Road Watford Hertfordshire WD24 4AL Tel: 01923 211290 Fax: 01923 233474 Email: ambulance@kerrylondon.co.uk Main address: Tel No: Email: Website: CQC Reg Number: Please provide similar details for any other companies or businesses (including associated or subsidiary companies) requiring cover under this insurance, below. Additional insured name and address: Year business established: How many locations do you operate from: ( If mobile then advise ) Total Income: Last completed financial year Forthcoming period UK law contracts EU law contracts US law contracts Other law contracts Wageroll: Clerical and Managerial Manual staff working on premises only (please give details) Manual staff working away from premises (please give details) Your Experience: Please confirm that one or more of the Principals has Yes: No: at least 5 years experience in the relevant industry? If No, please provide CV s for all principles.
Business Activities: Please give a breakdown of the type of business: % Patient transfers (low risk) i.e. geriatric, routine transfers between hospitals, care homes Non-routine patient transfers i.e. high dependency transfers Ambulance cover at events Organ transfers Blue light work First aid training Training in manual handling Air ambulance repatriation * - please fill in separate appendix Accident and emergency NHS work Primary provider / Back up contract - please delete as appropriate Other please specify Professional Persons: Please indicate the numbers of the following professionals involved : Paramedics First aiders Ambulance technicians EMT s Other please specify: Qualifications: What qualifications are held? Registration: Are you a member of any professional organization, or registered with any self regulating body? Yes: No: If yes please give details: General: Do you always undertake CRB checks including any Yes: No: work that is subcontracted? If no please give details: Records: Please confirm that all records, to date, and in future Yes: No: will be maintained for at least 10 years?
Medical Malpractice Limit of Indemnity required: 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 Other: Previous Insurance History: Do you carry, or have you carried, malpractice Yes: No: Insurance in the last 12 months? If yes please state: The name of the Insurer: Present limit of indemnity purchased: Excess under current policy: Premium being paid: Has the previous policy been on a claims made basis? Yes: No: If yes, what is the retroactive date? Has any Insurer ever cancelled your medical malpractice/professional indemnity policy, declined/refused to renew, or only accepted the risk at special terms? Yes: No: If yes please give details: Public Liability Limit of indemnity required: (if applicable) 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 Other: Employers Liability: Do you require Employers Liability cover? Yes: No: Professional Indemnity Extension: Do you require Professional Indemnity cover? Yes: No: (Aggregate limit of Indemnity for Professional Indemnity will be as per the Medical Malpractice Limit of Indemnity)
Claims: Please complete the claims questions for any risk now to be Insured under the following insurance covers: Are you aware of any shortcoming in your work that could lead to a claim being made against you? This could include, but is not limited to: i) A shortcoming or problem in your work which you cannot reasonably put right ii) A complaint about your work or anything you have supplied which cannot be immediately resolved iii) An escalating level of complaint on a particular project iv) A client withholding payment due to you after any complaint Yes: No: Are you aware of any loss from the suspected dishonesty Yes: No: or malice of any employee or self employed freelancer? Have you or any or your partners or directors either personally or in any business capacity been declared Yes: No: bankrupt or insolvent or made arrangements with creditors? Has any Insurer ever cancelled or withdrawn, your medical Yes: No: malpractice/professional indemnity policy, declined/refused to renew, or only accepted the risk at special terms? If you have answered Yes to any of the above, please provide full details: In respect of the following Insurance covers: Medical Malpractice, Professional Indemnity, Public Liability, Employers Liability: Has any claim or loss, whether successful or not, ever occurred or been made against you or any past or present partner, principal, director or employee in respect of any risk now to be Insured under the Insurance covers listed above (whether previously Insured or not)? Yes: No: If yes please provide details: Date Details Amount Remedial Action Please continue on a separate sheet if necessary:
Property Insurance: Do you require Insurance in respect of your Yes: No: Business premises? If yes please confirm the levels of cover required: Buildings Sum Insured: General Contents: Computer Ancillary Equipment: All risk cover in respect of Property away from premises: (Please list individual items with a value over 1,000) Item Description Value Is cover required for UK/EU/Worldwide? Additional expenses: (The necessary and reasonable additional costs and expenses you incur in order to continue your Business during the indemnity period resulting from an interruption to your Business caused by Insured damage to your premises/contents or any other property used by you at the Insured premises.) Sum Insured: Indemnity Period: 12 months: 24 months: Security: Please could you confirm the following Security is in place at the premises: Are final exit/external doors secured by means of either a mortise deadlock or rimlock confirming to or superior to Yes: No: BS3621, or a key operated multi-point locking system having at least three locking bolts? Do all ground and basement level opening windows and upper floor opening windows/skylights accessible from Yes: No: roofs, balconies, fire escapes, canopies, downpipes and other features of the building are secured by means of a key operated locking device or permanently screwed shut? Are the premises constructed with walls of brick, stone or concrete and roofed with slates, tiles or profile Yes: No: material? Are the premises protected by an intruder alarm, installed by a member company of NSI (National Security Inspectorate) and is connected to a central station by Yes: No: means of BT Redcare (or equivalent)?
Property Claims: Please can you confirm the following: Have you in the last 3 years had a single claim, loss or damage of 1,000 or more or incurred losses, Yes: No: damages or incurred losses, damages or claims of more than 5,000? Are you aware, after enquiry, of any potential disease or injury to an employee that may give rise to a claim? Yes: No: Have you had an Insurance or proposal cancelled, withdrawn, declined or made subject to special terms? Yes: No: Have you been convicted of or charged with any offence, other than a motoring offence or conviction spent under Yes: No: the Rehabilitation of Offenders Act 1974? Air Repatriation Services: Do you arrange the transportation and repatriation? Yes: No: If no, are you contracted just to perform the medical Yes: No: back up? When does your responsibility for the transportation begin and end? What medical staff would be used in repatriation? Are all registered medical practitioners members of a medical defense organization, or otherwise fully Insured Yes: No: for their own Malpractice, and do you retain records to ensure this? Do you accept liability other than under jurisdiction of the Yes: No: UK courts? In which Countries do you work? Declaration: You must complete this section. Please read the declaration carefully and sign at the bottom.
Material Information: Please provide us with details of any information which may be relevant to our consideration of your proposal for Insurance. If you have any doubt over whether something is relevant, please let us have details. If any material information is not disclosed we will be entitled to treat the Insurance as if it never existed. I/we declare that (a) this proposal form has been completed after proper enquiry; (b) it s contents are true and accurate and (c) all facts and matters which may be relevant to the consideration of our proposal for Insurance have been disclosed. I/we undertake to inform you before any contract of Insurance is concluded, if there is any material change to the information already provided or any new fact or matter arises which may be relevant to the consideration or our proposal for Insurance. I/we understand that non-disclosure or misrepresentation of a material fact or matter will entitle the Insurer to avoid this Insurance. I/we agree that this proposal form and all other written information which is provided are incorporated into and form the basis of any contract of Insurance. Name: Position within the company: Signature: Date: Information required for all policies that have Employers Liability cover; Employer Reference No (PAYE Ref):.. Company registration Number:.