THE HOLLARD INSURANCE COMPANY LIMITED INSURANCE PROPOSAL FORM FOR MEDICAL MALPRACTICE AND/OR LIABILITY INSURANCE FOR INSTITUTIONS Please answer ALL questions fully. If the space provided is insufficient, a separate sheet should be attached. The Declaration forming part of this Proposal must be signed by a Partner in the Practice and where cover is to include any Company through which the Practice provides professional services, the partner signing the Declaration shall be deemed to be the duly authorised agent of such company. Signature of this Proposal does not bind the Practice nor the Insurers to complete the Insurance. This Malpractice insurance policy will be issued on a Claims Made Basis. The cover applicable at the time of a circumstance or a claim being reported will be the cover applicable at that time, subject to the retroactive date stated on the Schedule page of the policy documentation. RESUMÉ OF COVER The following is a brief resumé of the cover proposed. The actual policy document, however, remains at all times the sole binding contract. The policy is in Three Sections. It is our recommendation that all these Sections be purchased in order to ensure there are no gaps in the cover. SECTION ONE: Medical Malpractice: Covering Third Party claims for damages and legal defence costs arising out of actual or alleged Malpractice. SECTION TWO: Public Liability: Covering legal liability for Third Party bodily injury or damage including legal defence costs other than Medical Malpractice or Products Liability. SECTION THREE Products Liability: Covering legal liability for Third Party bodily injury or damage including legal defence costs arising out of defective Products other than Medical Malpractice. 1
1. NAME OF PRACTICE(S): _ 2. HEAD OFFICE POSTAL ADDRESS: HEAD OFFICE PHYSICAL ADDRESS: Tel No. ( ) Facsimile No. ( ) E-Mail Address: Contact Person: Location of Branch Offices: 3. Please state the Owner(s) names and details of their experience and qualifications: Name Shareholding % Experience / Qualification/s 4. Are Public Funds or Private Funds or Endowments used to maintain the Institution, either in whole or in part? If so, please state percentages: % 5. Are any of the beds of the Institution or any of its services available to the community on a CHARITABLE basis? If so, please state percentages: % 6. Fee Income (This question must be completed accurately as the figures are used for rating purposes). When is your Financial Year End: What is your estimated fees for the coming 12 months: Please give gross fees (excluding VAT) received for the past three completed financial years: Financial Year: Gross Fees: R R R 2
7. Has the Institution been issued with the necessary licence by the Local Authority, enabling it to trade legally at the premises specified in answer to Question 2? If not, please advise submission date. 8. Is the Institution: (a) A member of a group of hospitals? If YES, please give details: (b) Affiliated to any other medical interest? If YES, please give details: 9. Please give brief description of the Institution s activities. 10. Please state the approximate division of your patients between: (a) Surgical % (b) Medical % (c) Orthopaedics % (d) Obstetrics % (e) Gynaecology % (f) Paediatric % (g) Ophthalmology % (h) ENT % (i) Drug Addiction % (j) Alcoholics % (k) Communicable % (l) Tubercular % (m) Senile/Aged % (n) Insanity % 11. Please state number of beds maintained: (a) Full pay beds or part-pay beds (other than bassinets for maternity cases): (b) Charity beds (other than bassinets): (c) Maternity beds (i.e. bassinets): 12. Please state average annual bed occupancy. (Can be calculated by noting the occupancy at the end of (or any specific day of) each month and dividing the aggregate total of 12 months figures by 12.) 13. Please state number of X-Ray machines owned or operated, and whether they are used for: (a) Diagnosis : No.: (b) Treatment : No.: Does the Institution give Radium, or any other forms of radio-active treatment? If so, please give details: 3
14. Please state number of employees in each of the following classifications: Medical Staff (a) Surgeons specialising in (b) Doctors of Medicine specialising in (c) Radiologists (d) Radiographers (e) Laboratory Technicians (f) Pharmacists (g) Name of Director of Nursing: Qualification(s): Year(s) Obtained: Nursing Staff: SRN s: Day Night SEN s: Day Night Auxiliary Nurses: Day Night Student Nurses: Day Night 16. (a) Does the Institution undertake the training of staff? If so, please give details: (b) Does the Institution undertake to ensure that all trainees carry out their duties under proper supervision 17. Does the institution maintain Clinics? (a) Type: (b) Whether free to patients: YES/NO or full pay/part-pay: (c) The number of Institution employed Clinic: Doctors: Nurses: (d) Estimated total number of patients per year: 18. Do your staff receive any formal medical malpractice risk management training? 19. Is the Practice currently insured for Professional Indemnity Insurance? If YES, please complete the following (applicants who are currently insured should attach a copy of the Schedule page of their current insurance policy as we can then verify the retroactive cover date): Name of Insurers: Indemnity Limit: Deductible: Expiry Date of Cover: 4
What products liability and public liability insurance does your Institution currently insure itself for: Name of Insurers: Indemnity Limit: Deductible: Expiry Date of Cover: 20. 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: 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, errors or omissions? If Yes, provide reasons why: 21. 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: 22. Quotations required: Indemnity Limit: Deductible/ First Amount Payable*: *This may vary depending on Insurers attitude to the deductible. 23. 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: 5
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 Declaration be the basis of the Contract between me/us and the Insurers. DATED SIGNATURE OF PRINCIPAL/PARTNER/DIRECTOR NAME OF PRINCIPAL/PARTNER/DIRECTOR _ 6