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Specialist Application

Medical Malpractice Insurance Application for Specialists

Dear Doctor,

Thank you for your interest in our Medical Malpractice Insurance service.

  • Please answer all questions, unless stated as not required.
  • If you do not understand any part of this document, please contact Michael Doyle (broker providing this service) prior to signing it.
  • The completed form will be submitted to our contracted insurers, who will each provide you with a quotation for your review.
  • Any contract of insurance with you shall be based upon the answers and information provided in this application form and any other additional information provided by you.
  • If a quotation is offered, coverage will only be in respect of the insured name as stated in the Personal Details section below.
  • Please ensure that you inform us promptly if your personal circumstances and/or scope of practice change and/or if new medico-legal incidents occur subsequent to completion and submission of this form.
  • Upon acceptance of the quotation we will send you a policy schedule and proof of cover.

Should you decide not to accept our quotation and you are currently insured with one of our contracted insurers then you are welcome to move across to us by signing a brokers appointment.

Advantages of making All in One Brokers your medial malpractice broker:

  1. Annual renewal premiums will be negotiated on your behalf.
  2. Assistance with claims
  3. Regular industry updates
  4. Possible immediate premium reduction
Yours sincerely,

Michael Doyle
083 709 0653

All In One Brokers

Authorized Financial Service Provider | FSP 30554
+27 10 596 2222
info@ai1.co.za

Disclosure, Privacy and Sharing of Information

DISCLOSURE
You must disclose all information which is material to it in deciding whether to provide insurance cover to you, including any facts or conduct which might lead to a claim being made against you. Failure to do so could affect your cover. If you are in doubt, then rather disclose.

If you do not understand any part of this document, please contact us prior to signing it. You will be bound by the answers which are given, and by the information provided by you in this proposal form.

It is in your interests to make sure that all information is correct and understood.

  • This proposal form will be submitted on your behalf to the Insurer, and has been compiled in such a manner as to provide the Insurer with as much detail as possible to enable the Insurer to evaluate the risk. Completion of this form does not bind either you or the Insurer to complete the insurance transaction.
  • To assist the Insurer in accurately assessing liability for rating purposes, you are requested to answer all the questions. Where a mark is
    required, please mark the appropriate box with an “X”.
  • Please answer ALL questions fully. Please note, replies such as “see your records”, or “as previously advised” are not acceptable. If the
    space provided is insufficient, a separate sheet should be attached.
  • You acknowledge that the personal information you supply is provided voluntarily and therefore constitutes specific, voluntary consent to the processing of such information by the Insurer.
  • Your personal information will be processed for: -
    • a. General and specific underwriting and risk assessment purposes;
    • b. Statistical research and / or reporting;
    • c. the legitimate interests of Genoa / Safire and / or yourself; and
    • d. any statutory or regulatory compliance (where applicable).
  • You have the right to request access to, and correction of, your personal information. You can instruct The Insurer/Underwriting Management Agency to cease the processing of your personal information at any time and, subject to the requirements of applicable South African law, request that the Insurer delete and/or de-identify such personal information.

PRIVACY

In order to provide you with appropriate insurance, the Insurer/Underwriting Management Agency may at times have to process / share your personal information.

The processing of the information will at all times be in the interests of the Policyholder and may include sharing of your personal information with insurers, re-insurers, underwriting managers, brokers, financial institutions, industry bodies, credit agencies and associated service providers (where applicable).

At all times the sharing of such information is limited to only that information which will allow the Insurer/Underwriting Management Agency to provide you with suitable insurance/replacement insurance, to allow the Insurer/Underwriting Management Agency to process claims on
your behalf, to allow the Insurer/Underwriting Management Agency to conduct surveys and marketing initiatives, and to allow the Insurer/
Underwriting Management Agency to correctly allocate premium payments.

We assure you that when the Insurer/Underwriting Management Agency share your personal information with selected service providers/
third parties, for the specific purposes outlined herein, that we will ensure that the appropriate protections of your personal information are in
place in accordance with our obligations under the POPIA.

The Insurer/Underwriting Management Agency will take all reasonable steps to protect the personal information held in our possession against loss, unauthorised access, use, modification, disclosure, or misuse.

By signing this form, you:

  • Acknowledge that the personal information you supplied is provided voluntarily and that you consent to the processing of such information for the purposes of providing you with insurance and for lawful business reasons/purposes. You further acknowledge that this consent can be revoked by you at any stage.
  • Consent to your underwriting, claims or credit information being retained on any shared database of the Insurer/Underwriting
    Management Agency whether your policy is active or has been cancelled.

Specialisation

Please choose your specialisation below.
  • Notice
  • Personal
  • Quotation
  • Practice
  • Credentials
  • Qualifications
  • PI Cover
  • History
  • Employment
  • Management
  • Records
  • Income
  • Scope
  • Anaesthetist
  • Cardiologist
  • Neurologist
  • Neurosurgeon
  • Obstetrician and Gynaecologist
  • Opthamologist
  • Orthopaedic Surgeon
  • Paediatrician
  • Physician
  • Plastic & Reconstructive Surgeon
  • Radiologist
  • Surgeon (General)
  • Urologist
  • Attestation
    • Signature

    Have a question?

    Please let me know how I can help.

    medical-malpractice-insurance-michael-doyle-dark

    Michael Doyle

    All in One Brokers
    FSP 30554

    Email: michael@ai1.co.za
    Mobile: +27 83 709 0653