MEDICAL MALPRACTICE INSURANCE PROPOSAL FORM

INSTRUCTIONS

Please ...
 Print clearly or type
 ANSWER ALL QUESTIONS COMPLETELY
 If there is insufficient space to completely answer a question, continue on a separate sheet of
your firm’s letterhead indicating the number of the question.
 The form must be signed and dated by a Partner or Principal of the firm.
 Post the completed application through the broker of your choice to:
_____________________________________________________________________________
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_____________________________________________________________________________
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IMPORTANT NOTICE

It is your duty to disclose all material facts to Underwriters. A material fact is one that is likely to
influence an Underwriter’s judgement and acceptance of your proposal. If your proposal is a
renewal, it should also include any change in facts previously advised to Underwriters. If you are
in any doubt about facts considered material, disclose them. FAILURE TO DISCLOSE could

prejudice your rights to recover in the event of a claim or allow Underwriters to void the Policy.

Section A – General Information

1. Name and principal address of the Establishment(s) to be insured:

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2. If other locations are to be covered by the proposed insurance, please list them hereunder
together with details of the use to which they are put.

3. Establishment(s) is (are) owned by:

4. How long had the Establishment(s) been operated by the present owners? If change, when?

5. Is the Establishment registered as a charity?

If it is, what is the approximate percentage of charity patients?

6. What is the approximate percentage of patients from:

a) Government/public ________________________
b) Private/funding ________________________
c) Charitable ________________________

7. What kind of Establishment is registered at the specified locations listed above?

8. Is (are) the Establishment(s) licensed to operate at the addresses declared under 1 and 2
above?

Section B – Personnel Information

1. State the number of employees in each of the following classifications:

(Please state details regarding other departments and qualifications on a separate sheet.)

Speciality Number of Qualifications Graduate from, when, experience?

physicians


2. State the number, qualifications and further education of the nursing staff:
3. Does the Establishment employ
a) students?

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b) trainees?

_________________________________________________________________________
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c) X-ray technician

_________________________________________________________________________
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d) laboratory technicians?

_________________________________________________________________________
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e) other medical staff? Please give details about number and qualification.

_________________________________________________________________________
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4. Does the Establishment have
24h-readiness with physician and nursing service?
24h-readiness with specialist service?
State the personnel availability at weekend and night:

Section C – Information about departments and patient capacity

1. Please give further information in the following table:

2. Percentage of cases  3 days duration of treatment:

3. Percentage of cases > 30 days duration of treatment:

4. State the number of beds available:

5. Medical-technical equipment:
a) X-ray YES  Number:
b) CT YES  Number:

6. Other equipment: N.A.

a) pharmacy YES  NO 
b) blood bank YES  NO 
c) sperm bank YES  NO 
d) nursing school YES  NO 
e) medical research laboratory YES  NO 

7. Tele-medicine: N.A.
a) Do you use tele-diagnosis? Please provide full information (departments, type of tele-
diagnosis, frequency etc.).
b) Do you use tele-therapy? Please provide full information (departments, type of tele-
therapy, frequency etc.).

c) Is the use of tele-medicine limited to national activities or are foreign physicians, hospitals
and/or other institutions involved? Please provide further details.

d) Are there any contractual agreements in respect of tele-medicine?

e) Please provide full details of operating procedures i.e. records, diagnosis etc. in respect
of tele-medicine.

Section D – Treatment Statistics

1. Give some statistics about the department obstetrics: N.A

Average deliveries p.a.: _____________________
thereof
- Caesarean sections _____________________%
- Premature deliveries _____________________%
Monitoring for gravidaes and foetuses (e.g. CTG)
_______________________________________________
 _________________________________________________________________________
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2. Please fill in the following table: N.A.

Speciality Number of operative procedures per department

Surgery ___________________________________________________________________
special departments _
e.g. Cardiac Surgery ___________________________________________________________________
Neurosurgery _
Paediatric surgery ___________________________________________________________________
Plastic surgery _
Traumatology ___________________________________________________________________
Vascular surgery _
Other ___________________________________________________________________
_
___________________________________________________________________
_
___________________________________________________________________
__

Dental medicine General Dentistry, Prosthodontics, Orthodontics.

3. State the main surgical procedures (e.g. Endoprothetics): N.A.

_________________________________________________________________________
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_________________________________________________________________________

4. State the main non-surgical procedures (e.g. geriatric medicine, invasive cardiology): N.A.

_________________________________________________________________________
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 _________________________________________________________________________
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5. State complications following treatment as a percentage of all patients treated: N.A.

a) wound-healing impairment (operative specialities) __________%
b) joint- and bone infections (operative specialities) __________%
c) generalised infections __________%
d) pulmonary embolism __________%
e) decubitus __________%
f) patients with nerval dysfunctions (e.g. paralysis) __________%
g) patients with impaired consciousness (e.g. apallic syndrome) __________%

Section E – Information about Quality and Risk Management

Give some information concerning your Quality Management:

N.A.
1. State all standards existing in the Establishment e.g. guidelines, standards as nursing
standards, hygiene and disinfection plans:

_________________________________________________________________________
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_________________________________________________________________________
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2. Case and mortality conferences? YES  NO 

 _________________________________________________________________________
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3. Mortality and complication statistics? Please give the mortality rate per department on a
separate sheet.

_________________________________________________________________________
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4. How is the co-ordination/co-operation of and between the employees arranged? How is the
exchange of information effected? Give some details.

_________________________________________________________________________
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_________________________________________________________________________
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5. State the number of personnel involved in Quality Management. Is anybody employed full-
time for this job or are several of the staff responsible among other things?

_________________________________________________________________________
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_________________________________________________________________________
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Some questions regarding your Risk Management:

1. Do you act with
a) incident reporting?
 b) peer reviews?

2. Give details about co-operation with external Establishments (e.g. insurance, medical
organisations):
.

3. Do you employ Risk Management staff? Is anybody employed full-time for this job (internal
or external) or are several of the staff responsible among other things?

4. How is the communication between physician and patient arranged? How is the exchange of
information effected?

Section F – Information about the previous insurance and claims history

1. Identify the present Insurer(s) of the Establishment:

_________________________________________________________________________
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2. Has prior coverage been on a claims made basis? YES  NO 

If YES, what is the retroactive period and the extended reported period?
______________________________
3. Which are the present policy limits of liability insurance?

_________________________________________________________________________
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4. What is the deductible, if any?

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5. What is the expiry date of the present policy?

 _________________________________________________________________________
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6. Has any application for this type of insurance cover ever been
a) declined? YES  NO 
b) cancelled? YES  NO 
c) required special terms? YES  NO 
If the answer to any of the above is YES, please give details:

_________________________________________________________________________
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7. What is the total income of the Establishment and its affiliated clinics and units?

_________________________________________________________________________
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8. Are clinics maintained? If so, please indicate the type.

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9. Limit of Indemnity required:

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10. List any claims made against the Establishment or its staff during the last 10 years.
Date of Date of Amount Amount Amount Details including nature of the allegations
Accident Claim Claimed Paid Outstanding and details of Claimant and relevant Insurer
11. List any circumstances/complaints which may give rise to a claim or suit being made
against the Establishment.
Date of Circumstance / Complaint Details including nature of the Complaint and details of the Complainant

12. Have all of the above been notified to and accepted by your previous insurers? YES

 NO 
If NO please provide full details:

_________________________________________________________________________
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DECLARATION

I/We declare that the statements and particulars in this proposal are true and that I/We have not
misstated 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 whether occurring
before of after completion of the Contract of Insurance. Signing this Proposal Form does not bind
the Proposer or the Insurers to complete this Insurance.

Dated this ............ ...............................