1) NAME/S (Including Trading Names) of the Proposer/S
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INFORMATION TECHNOLOGY
PROPOSAL FORM
for
Insurance effected through Williams Insurance Management Limited
15 St Mary at Hill, London EC3R 8EE Tel: 0203 058 1095 Fax: 0870 4585881 E-mail: [email protected] Registered Office: as above Registered in England: 4851546 Authorised and regulated by the Financial Conduct Authority IMPORTANT NOTICE
This proposal must be completed and signed by a Principal, Partner or Director of the Proposer. The Person completing and signing the form should be authorised by the Proposer to do so and should make all necessary enquiries of his fellow Partners, Directors and Employees to enable all the questions to be answered.
All questions must be answered to enable a quotation to be given.
Completing and signing this Proposal does not bind the Proposers or Underwriters to enter a Contract of Insurance.
If there is insufficient space to answer questions, please use an additional sheet and attach it to this form (Please indicate section number).
E.U. DISCLOSURE CLAUSE (UK)
ONLY APPLICABLE TO PRIVATE INDIVIDUALS AND SOLE TRADERS, WHERE THERE IS A LLOYD'S PARTICIPATION IN THE INSURANCE PLACEMENT.
Notice to the Proposer/Assured.
The Parties are free to choose the law applicable to this Insurance Contract. Unless specifically agreed to the contrary this insurance shall be subject to English Law.
Any enquiry or complaint should be addressed in the first instance to your Broker.
If you are not satisfied with the way a complaint has been dealt with you may ask the Complaints and Advisory Department at Lloyd's to review your case without prejudice to your rights in law. The address is:
Complaints and Advisory Department Lloyd's, One Lime Street, LONDON EC3M 7HA Telephone 020 7623 7100.
LSW 1002 (07/99) (amended). Medical Malpractice Proposal Form Section 1. General Information 1
1. Full name and address of proposer ……………………………………………………………...... ……………………………………………………………...... ……………………………………………………………......
2. Date established ……………………………….
3. How long have you operated under the present management ……………………………………………………………......
4. Full description of activities ……………………………………………………………...... ……………………………………………………………...... ……………………………………………………………......
……………………………………………………………...... 5. Do you anticipate any changes to these activities in the next 24 months? ……………………………………………………………...... ……………………………………………………………...... ……………………………………………………………......
6. Is any work sub-contracted? ……………………………………………………………...... a) If YES, please give details ……………………………………………………………...... ……………………………………………………………...... b) Do you require all sub-contractors to maintain their own insurance? ……………………………………………………………...... ……………………………………………………………......
7. Is there any additional information that should be made known to Underwriters so that they may form a proper estimation of the risk? ……………………………………………………………...... ……………………………………………………………...... ……………………………………………………………...... ……………………………………………………………...... ……………………………………………………………...... ……………………………………………………………...... ……………………………………………………………...... ……………………………………………………………...... ……………………………………………………………...... 8. Please give details of your gross income /fees: a) For the current financial year ……………………………………………………………...... b) For the next financial year ……………………………………………………………...... c) Approximately split by: Private ……………………………………………………………...... Govt / Public ……………………………………………………………...... Charitable ……………………………………………………………...... d) Approximately split by: UK (Excl IOM & / or Channel Islands) ……………………………………………………………...... Europe (Incl IOM) ……………………………………………………………...... USA / Canada ……………………………………………………………...... ROW ……………………………………………………………...... e) Largest fee for any one client ……………………………………………………………...... f) Average fee for any one client ……………………………………………………………......
9. Please list your three largest projects undertaken in last 5 years (Including name of client and fee earned) 1. ……………………………………………………………...... 2. ……………………………………………………………...... 3. ……………………………………………………………...... 10. Please enclose copy standard contract
2 Section 2. Professional Services
1. Do you provide any training / teaching facilities? ……………………………………………………………...... ……………………………………………………………......
2. Do you provide any facilities for the sterilisation of instruments? ……………………………………………………………...... ……………………………………………………………......
3. Are any counselling services provided? ……………………………………………………………...... ……………………………………………………………......
4. Are you duly licenced in accordance with the Care Standards Act 2000 and are you registered with the Care Quality Commission (CQC) or equivalent body? ……………………………………………………………......
5. Has your registration with the CQC (or equivalent body) ever been? a) Approved with conditions …………………….. b) Cancelled ...……………………………………. c) Varied …………………………………………... d) Other..…………………………………………..
6. Have you ever been in dispute with the CQC (or equivalent) regarding an assessment /Inspection Report? ……………………………………………………………......
7. Have you been investigated by the CQC or equivalent body, or do you have an investigation pending? ……………………………………………………………......
8. Have you met all recommendations and requirements from your last CQC (or equivalent) Inspection Report? ……………………………………………………………...... If you have answered YES to any of the above, then please enclose full details
9. Please provide the split of activities between: a) Residential Care ………………….….. b) Care in the Community ……………… c) Respite Care ………………………….. d) Occupational Health …………….…… e) Outreach Work ……………….……….
10. Please provide approximate split between Private and NHS patients ……………………………………………………………......
11. Please advise how patients are referred? ……………………………………………………………...... ……………………………………………………………...... ……………………………………………………………......
12. Do you undertake any work for the NHS, where liability is covered by the CNST? ……………………………………………………………...... If YES, then please enclose full details
13. Please provide percentage split or number of patients in the following categories: a) A&E……………………………………………… b) Antenatal……………………………………...… c) Assisted Conception…………………………... d) Clinical Trials…………………………………… e) Cosmetic…...…………………………….……... f) Dental…………………………………………… g) Diet / Nutrition…………………………..……… h) Disability………………………………………… i) Drug / Alcohol……………………………….…. j) Gender Reassignment………………………… k) HIV / HEP (Including Counselling)…………… l) Intermediate Surgery………………………….. m) Laser Eye Surgery…………………………….. n) Major Surgery………………………………….. o) Maternity / Obstetrics………………………….. p) Minor Surgery………………………………….. q) Paediatric……………………………………….. r) Plastic / Reconstructive……………………….. s) Psychiatric……………………………………… t) Residential / Nursing Care……………………. u) Respite………………………………………….. v) STI………………………………………………. w) Terminally Ill……………………………………. x) Other (please specify) ……………..………………………………………………… ……………..………………………………………………… ……………..…………………………………………………
14. Please state total bed numbers and Average Daily Occupancy ……………..………………………………………………… If applicable, please provide number of beds maintained in: a) A&E…….………………………………………... b) Beds (Excluding A&E)…………………………. c) Cots……………………………………………… d) ICU / ITU…………………………………………
15. Please provide total number of patients /clients last year ……………………………………………………. 16. Please estimate the number of patients /clients for the coming year ………………………………………………….………......
Section 3. Staffing 1. Please provide the number of employed / self-employed staff in each of the following classifications: EMP S/EMP a) Anaesthetists…...... b) Auxiliaries / Carers…………………………….. c) Dentists…………………………………………. d) Doctors………………………………………….. e) Gynaecologists………………………………… f) Lab Technicians……………………………….. g) Midwives………………………………………... h) Nurses…………………………………………... i) Obstetricians…………………………………… j) Paramedics / ECP’s…………………………… k) Pharmacists…………………………………….. l) Radiologists…………………………………….. m) RMOs…………………………………………… n) Supplementary Professionals (Including Therapists)………………………….. o) Surgeons……………………………………….. p) Other (please specify)…………………………. ……………..………………………………………………… ……………..………………………………………………… ……………..…………………………………………………
2. Do you require the following staff to maintain their own cover, through their professional body or equivalent? a) Dentists………………………………...... b) Doctors / Physicians…………………...... c) Midwives…………….………….………...... d) Nurses………………………………………...... e) Occupational Nurses………………………….. f) Occupational Physicians……...... g) Paramedics / ECPs……………...…………….. h) Pharmacists……………………………...... i) Psychiatrists……………………………………. j) Psychologists…………………………………... k) Surgeons……………………………………….. l) Therapists / Other Professionals (Including Counsellors and Complementary Practitioners)…………...... If NO, then please provide full details ………………………………………………………… ………………………………………………………… ………………………………………………………… (Please note that additional information may be required if specific cover for any of the medical professionals listed above is to be included within your own Policy) 3. Do you ensure that all references, qualifications and status to work are taken up and that all appropriate police checks are carried out on all staff? ………………………………………………………… If NO, then please provide full details ………………………………………………………… ……………………………………………………...... ………………………………………………………… Section 4. Insurance 1. Please provide the following: a) Current Insurer ………………………………… b) Current Limit …………………………………… c) Current Deductible ……………………………. d) Current Premium ……………………………… e) Current Expiry Date ……………………………
2. Have any Lloyd’s or any other Insurers ever cancelled, declined, refused to renew or only accepted on special terms, your Malpractice or Public Liability Insurances? ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………......
3. Have any claims for Malpractice or Negligence ever been made against you or are you aware of any circumstances which might result in such a claim being made against yourselves? If YES, then please provide full details on an additional sheet, including quantum where applicable ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………...... 4. Please indicate which limit / limits you require quotations for: D 1,000,000 D 2,000,000 D 5,000,000 D 10,000,000 D Other (please specify) ………………………..
5. Do you have any other Malpractice or Public Liability Insurance? ……………………………….…………………………...... ……………………………….…………………………......
Section 5. Additional Information (Maternity/Obstetrics) 1. Please state the number of deliveries per annum ……………………………….…………………………...... 2. Please state the number of deliveries in the following categories: a) Multiple Births………………………………….. b) Stillborn…………………………………………. c) At less than 32 weeks gestation……………… d) At less than 1501 grammes…………………... e) With an Apgar score of less than 6 at five minutes…………………………………….. f) Admitted to the NICU / SCBU………………… g) Of those admitted to the NICU / SCBU, how many are transferred from other hospitals or from home births? ……………………………….…………………………......
3. Do you have a formal agreement with any other hospital for the transfer of maternity patients / infants in the event of a problem during the birth? ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………......
4. Are an Obstetrician, an Anaesthetist and a Paediatrician available 24 hours per day? ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………......
5. Are a secondary Anaesthetist and Obstetrician on call 24 hours a day? ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………......
6. Can Midwives attend births without the presence of a Doctor? ……………………………….…………………………...... ……………………………….…………………………......
7. Can outside Doctors attend their own patients? ……………………………….…………………………...... ……………………………….…………………………......
8. Can emergency caesarean sections be performed immediately, 24 hours a day? ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………......
Section 6. Additional Information (Surgical and Non-Surgical Cosmetic Procedures)
1. Please provide percentage split of elective cosmetic surgery offered under the following categories: a) Abdominoplasty………………………………... b) Breast Surgery…………………………………. c) Brow Lift………………………………………… d) Face Lift………………………………………… e) Hair Transplant………………………………… f) Laser Eye Surgery…………………………….. g) Liposuction……………………………………... h) Rhinoplasty……………………………………... i) Scalp Surgery…………………………………... j) Thighplasty……………………………………… k) Thread Lift.…………………………………….... l) Other (please specify)………………………… ……………..………………………………………………… ……………..………………………………………………… ……………..…………………………………………………
6. Additional Information (Surgical and Non Surgical Cosmetic Procedures) – Cont/d
2. Please provide percentage split of elective non-surgical cosmetic procedures offered under the following categories: a) Autologous Cell Therapy……………………… b) Bio Skin Jetting…………………………………. c) Botulinum Toxin Injections…………………….. d) Chemical Peel………………………………….. e) Dermabrasion………………………………….. f) Dermal Filler……………………………………. g) Electrolysis……………………………………… h) Laser Hair Removal…………………………… i) Light Rejuvenation Therapy…………………… j) Laser Skin Resurfacing…..………………….... k) Lipotherapy……………………………………... l) Mesotherapy……………………………………. m) Micro-Current Treatment………………………. n) Microdermabrasion…………………….....…… o) Micropigmentation……………………………... p) Microsclerotherapy…………………………….. q) Micro-Thermocoagulation Treatment………… r) Plasma Skin Rejuvenation…………………….. s) Radiofrequency Treatment……………………. t) Other (please specify)…………………………. ……………………………….…………………………...... ……………………………….…………………………......
3. Are all Doctors / Surgeons on the GMC’s Specialist Register for cosmetic surgery or Specialist Register in their field of surgery? ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………......
4. Please provide details of the following, for all individuals undertaking procedures/treatments: a) Name b) Qualifications c) Years of Experience on cosmetic procedures d) Numbers of procedures performed e) Confirmation of membership of professional associations / organisations (Additional back page is provided for this information)
5. Please provide an estimate of the % of patient referrals from the following: a) GPs / Consultants ……………...…..…. b) Self-Referral ……………………..……. c) Other (please specify) ……………….. 6. a) Is the patient’s medical history always obtained from their own GP prior to treatment? ……………………………….…………………………...... b) If NO, please provide details of the precautions taken in relation to patients that may have existing medical conditions. ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………...... 7. How are patients informed of the nature of the surgery or treatment, risks involved, side effects, results and how long they will last? ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………...... 8. Please enclose standard consent form/s
6. Additional Information (Surgical and Non Surgical Cosmetic Procedures) – Cont/d
9. Do all patients receive a consultation with the Doctor / Surgeon / Nurse undertaking the cosmetic procedure prior to surgery/treatment ……………………………….…………………………...... 10. Are all patients given a ‘Patients Guide ’detailing clear and accurate information in relation to the treatment, costs and other services? ……………………………….…………………………...... If NO, please provide details ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………...... 11. Please provide full details of any laser treatments, including the equipment make, Model, circumstances of use / conditions treated ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………......
Section 7. Additional Information (Nursing & Domiciliary Care Agencies)
1. Please provide your approximate number of temporary staff supplied, split as follows: a) Professionally Qualified Nurses…………….. b) Auxiliary Nurses…………..…………...... c) Home Helps...……………...…………………… d) Other (please specify)...…..………………...... ……………………………….…………………………...... 2. a) What percentage of placements are permanent? ……………………………….…………………………...... b) Are you expecting any change in this figure over the next 12 months? ……………………………….…………………………...... ……………………………….…………………………...... ……………………………….…………………………......
3. Please provide percentage split of clients in the following categories: a) Care home.………………………………………...….. b) Hospital.…………………………………………. d) Hospice………………………………………….. c) Client’s own home.…………………………...... d) Other (please specify)...……………….………. ……………………………….…………………………......
4. Please provide percentage split of type of client in the following categories: a) Elderly…..……………………………...……….. b) Physical Disability……………………...………. c) Learning Disability……………………………… d) Palliative Care………………………………….. e) Children / Young Adults……………………….. f) Other (please specify)…...…………….………. 8 Declaration I / We hereby declare that the above statements and particulars are true and that I / we have not suppressed or mis-stated any material facts and I / we agree that this Proposal Form shall be the basis of the contract with the Underwriters.
Name of the Proposer: ……………………………………. Signature:…...... Official Position:...... Dated the…...... day of...... 20...... This Proposal Form, duly completed, together with any supplementary information, must be signed in ink. Signature of the form does not bind the Proposer or the Underwriters to complete the insurance.
NOTICE TO SOLE TRADERS / INDIVIDUALS: The European Union Third Non-Life Directive on Pre-Contractual Disclosure Requirements requires you to be provided with the following information prior to a contract being concluded:
Notice to the Proposer / Assured: The Parties are free to choose the law applicable to this Insurance Contract. Unless specifically agreed to the contrary, this insurance shall be subject to English Law. Any enquiry or complaint should be addressed in the first instance to your Broker. If you are not satisfied with the way a complaint has been dealt with, you may ask the Complaints Department at Lloyd’s to review your case without prejudice to your rights in law. The address is: Complaints Department, Lloyd’s, One Lime Street, London, EC3M 7HA. Telephone: 020 7327 6950.
9 Continuation sheet (Please ensure that your number each additional point to correlate with the sections and questions in the Proposal Form)