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Clinic & Hospital Application

Clinic & Hospital Application

Medical Malpractice Insurance Application for Clinics & Hospitals

Dear Clinic/Hospital Administrator,

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

  • 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.
  • You must disclose to the Underwriters 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.

 

Privacy and Sharing of Information

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.

 

The following documents must be returned with this Proposal Form

1) Completed, signed and dated proposal form
2) Department of health registration certificate in province where operating
3) Institution’s letterhead
4) Claims Information (if applicable)
5) Proof of previous insurance (if moving from another insurer)

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

Details of the entity to be insured (“the Proposer”)

Have you ever carried out Medical Services under a different name?

If cover is required for more than one location, please list all the location addresses below

GET YOUR TEAM TO HELP COMPLETE THIS APPLICATION

Please add the details of your practice staff you would like to complete relevant sections of this application.

We will send an email to them (and you) 60 minutes from you last activity on this application.

In this email there will be a link that links back to the partially completed form. This makes it easy to complete the form as and when you get a chance in your busy schedule.

Insurance History

Are you in the present or have you in the past been Insured, for the type of Insurance now being proposed?

For the type of Insurance now being proposed, has any Insurer ever:

Required an increased premium or imposed special terms?
Refused to accept or renew any insurance?
Cancelled the insurance?

Activities of Proposer

Where does the applicant provide services to their clients? (Please tick all appropriate boxes):
Does the applicant sell or distribute any medical/pharmaceutical products and/or medical devices? (Not including those used on or by patients in the course of their treatment by the applicant)
Does the applicant manufacture, alter, re-label, mix or blend products/devices in any way?

Applicable Services

Please tick all applicable services provided at your facilities (please note this does not constitute a comprehensive list of all medical/ surgical specialties/departments): * Denotes further information required below if ticked:

Staff Compliment

Registered Medical Practitioners

Repeater

Other Staff

Are all professionally qualified clinical staff registered with the applicable regulatory body?
Are all professionally qualified clinical staff adequately trained?
Where professionally qualified clinical staff require supervision, is there appropriate management to perform a supervisory role?
Do you require that all non-employed medical staff to carry their own insurance?

Abortion Clinic

Abortion Clinic

GESTATION

Ambulance Services

Ambulance Services
Are ambulances used as first responders?
Are ambulances used as patient transport?

Anaesthesiology

Anaesthesiology

Do you use nurse anaesthetists?
Do they carry separate insurance?
Are nurse anaesthetists or any other practitioners assisting during anaesthesia care supervised by a qualified anaesthesiologist at all times?
Do you ensure that there is a fully qualified anaesthesiologist on site at all times?

Bariatric Surgery

Number of weight loss operations performed in last 12 months by type as follows:

Do you provide bariatric services to patients under 18 years of age?
Does your bariatric programme have specific patient exclusion criteria?
Do you always obtain signed informed consent from patients prior to performing bariatric procedures?

Blood / Sperm / Tissue Bank

Is any blood, blood product, or other human tissue bought or obtained from outside your principal country of operation?
Are all blood or blood products tested before use?
Do you outsource any of your blood tests?
Do you contractually require the outsourcing company to carry suitable professional liability insurance?

Surgery

Repeater

Are any of your facilities designated referral centres for any surgical service?
Can a house officer or resident perform surgery under general anaesthetic without an attending surgeon being present?
Do both surgeon and anaesthetist conduct informed consent counselling with the patient in person prior to surgery?
Do both surgeon and anaesthetist always obtain signed informed consent from patients prior to surgery?
Are patients provided with written material routinely as part of the consent procedure?
Do you use any of the following?

Telemedicine

Do you provide primary (patient to doctor) or secondary (doctor to doctor) telemedicine?
Do all providers use standardised clinical protocols when conducting telemedicine consultations?
Do you contractually require that institutions to whom you provide secondary telemedicine services indemnify you?
Do you provide telemedicine services outside of the Republic of South Africa?

Obstetrics & Midwifery

Please provide the number of live deliveries by type as follows:

Please provide the number of still deliveries by type as follows:

Please provide the number of live deliveries by type as follows:

Please provide the number of still deliveries by type as follows:

Is continuous electronic foetal monitoring performed on all patients in active labour?
Do you provide 24/14 on-site attending Obstetrician coverage at all sites with a maternity department?
Is an attending Obstetrician required to review all foetal monitoring strips periodically during labour and delivery?
Can caesarean sections be performed within 30 minutes 24 hours per day?
Are you responsible for any home births or births performed outside your hospital premises?
Do you provide midwife-led birthing?
Do you conduct any high-risk birthing programmes (eg high gestational weight, breached vaginal delivery, multiples etc)?
Do you use any form of obstetrical simulation training?

Emergency Services

Do you provide 24/14 on-site attending emergency medicine physician/registrar coverage at all sites with an emergency department?
Do any of the emergency department staff routinely work more than a 12 hour shift?
Do you attempt to follow up with all patients who leave the emergency department against medical advice or without being seen by a clinician?

Clinical Trials

Are clinical trials performed at the hospital?
Are all your clinical trials carried out at your premises?
Is each prospective trial subject to a full risk analysis?
Do all trial subjects sign an informed consent form prior to participation in a trial?
Do you conduct any form of research, testing or experimental activities in the following categories?

Risk Management

Is it mandatory that all your patients sign a consent form for consultations?
Are accurate and descriptive records of all medical services and procedures kept?
How are your patient records secured?
Please complete the following information for all types of inpatient beds:

Please complete the following information for all types patient visits:

Names and qualifications of directors/owners

Financial Information

REQUIRED COVER

State the LIMIT OF INDEMNITY and EXCESS required:

PREVIOUS LOSSES / EXISTING CIRCUMSTANCES

Is any Principal, aware of any circumstance which might:

Require an increased premium?
Give rise to a claim against the Proposer, any predecessor or any past or present Principal?
Cause any loss to the Proposer, any predecessor or any past or present Principal?
Otherwise affect the consideration of this proposal for insurance?
Have any Principals or Employees of the practice had any civil or criminal actions where there was a finding of liability or guilt?
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?
Have you or any Principals or Employees ever been investigated, or are currently under investigation by the relevant professional regulatory body overseas / medical scheme?
In respect of ANY of the risks to which this proposal relates, has any Claim been made (whether successful or not) against the Proposer or any past or present Principal?

If YES, please identify details:

Have you ever engaged in a similar activity under a different name?

Public Liability

Do you require Public Liability?

Are all buildings owned or used by you in a good state or regularly maintained / repaired?

Are the following regularly checked, serviced and repaired by fully qualified engineers?

Air Conditioning Units
Electricity Generators (including any Emergency Backup Generators)
Escalators
Heating Systems and Boilers
Hoists
Incinerators
Lifts
Water Tanks
Sprinkler System
Do you ensure that all subcontractors carry their own insurance?
Does the insurance as per include Public liability insurance?
Does your insurance as per include Workers’ compensation insurance?
Do you require copies of these policies or inspect copies of these policies?
Are staff instructed in and kept regularly appraised on fire and emergency procedures?
Is there an emergency electrical backup system in place?
Are there facilities for safe collection, storage and disposal, in accordance with current guidelines or legislation of Sharps?
Are there facilities for safe collection, storage and disposal, in accordance with current guidelines or legislation of Dressings, clinical and surgical waste, etc.?
Do you ensure that blood and blood products are safely disposed of, in accordance with current guidelines/legislation?
Do you ensure that all other waste are safely disposed of, in accordance with current guidelines/legislation?
Are floors cleaned daily?
Are wet signs displayed where floors are wet?
Are there any steps at your Company’s business premises?
If YES to the above question, please state whether there are hand railings or anti slip tape on the stairs?
Is your business premises kept clear of clutter?
Does the access into your business premises cater for the elderly or disabled?
Are disclaimers present in and around your business premises and in the parking area?
Is there safe parking at your business premises?
Is your business premises armed at night or are they monitored by surveillance or security?
Does your business premise have fire exits?
Is all fire equipment regularly serviced?
Do the premises comply with current fire precaution and prevention requirements?
When clients leave items behind at your business premises, are these stored in a safe place until they are returned?
Please indicate the Public Liability Limit required:

Product Liability

Do you require Product Liability?

Please provide details of all products manufactured, sold or distributed by you:

Are your products sold directly to customers or through wholesalers, distributors or retailers?
Have any of your products been discontinued / recalled in the last 5 years?
Are quality controls in place and how are these currently determined?
Do your products carry labels/packaging and/or information sheets which provide instructions and or information which has been reviewed and/or approved by a legal firm practicing within the export markets where the products are being sold?
Do your products carry labels/packaging and/or information sheets which provide instructions and or information regarding the correct use/storage and/or warnings of potential hazards?
Do your products carry labels/packaging and/or information sheets which provide instructions and or information in relation to medical treatment and/or remedial treatment action to be taken in the event of an accident, consumption or the misuse of the product?
Are any product warranties supplied with the product?
Please indicate the Public Liability Limit required:

Additional Information

Is there any further information that should be made known to the Underwriters in order that they may form a proper estimate of the risk?

Maximum file size: 268.44MB

Declaration & Signature

Signing this proposal form binds neither the proposer to complete this insurance, nor does it bind the insurer to accept the proposal.
It is agreed that all written statements and attachments furnished to the insurer in conjunction with this proposal are hereby incorporated
by reference into this proposal and made part thereof. It is understood and agreed that the insurer has relied upon this proposal and
attachments, which shall be the basis of the insurance contract.
The undersigned is an authorised signatory of the Proposer and certifies that reasonable inquiry has been made to obtain the answers
herein which are true, correct and complete to the best of his/her knowledge and belief. We undertake to inform the insurer of any
material alteration to these facts, whether occurring before or after completion of the insurance contract.