Medical Indemnity Indication Form

Your details:

Full Name

Mobile Number

Date Of Birth

Area of Surgical Specialty

Date commenced Private Practice

Gross Private Practice income (before expenses), ex. Medico legal: (Details for the last financial year)

Gross Private Practice income (before expenses), ex. Medico legal: (Details for the current financial year)

Gross Medico Legal income (before expenses): (Details for the last financial year)

Gross Medico Legal income (before expenses): (Details for the current financial year)

Please provide total number of patients for:

In-patients (Details for the last financial year)

In-patients (Details for the current financial year)

Day Case Surgery (Details for the last financial year)

Day Case Surgery (Details for the current financial year)

Non-Surgical Treatments/Injections (Details for the last financial year)

Non-Surgical Treatments/Injections (Details for the current financial year)

Consultations (Details for the last financial year)

Consultations (Details for the current financial year)

Medico legal reports (Details for the last financial year)

Medico legal reports (Details for the current financial year)

What is the approximate split between consultations and procedures (including endoscopies) performed:

Do you perform any of the following roles: - MAC Chair, member of MAC, Clinical Supervisor, Training Programme Director, Examiner or Other

Do you treat any elite/ professional sports people or high profile (media, TV etc) patients?

Do you have any retirement plans (Private Practice, NHS or Medico Legal):

Have you ever been or are you currently subject to any complaints, claims, disciplinary investigations or circumstances which could lead to a claim, either in the UK or overseas:

Current Insurance Details

Current indemnity provider:

Current Premium:

Required start date:

Any retroactive cover required?: (If, yes, state the dates required)

Any other supporting or relevant information:

The completion of this form will allow for an indication of price. To get an accurate price please ask us for a full application form and supplementary questionnaire relating to your specialty. Terms may also be subject to a confirmed claims experience. If you have any questions please call 01935 424085 to speak to an advisor.

Data Protection Act – All personal information supplied by you will be treated in confidence by Medical Insurance Consultants Ltd and will not be disclosed to any third parties except where your consent has been received or where permitted by law. In order to provide you with products and services this information will be held in the data systems of Medical Insurance Consultants limited or our agents or subcontractors.

Accredited

Medical Insurance Consultants Ltd is authorised and regulated by the Financial Conduct Authority and is entered on the Financial Services Register under reference 309026.

Personal

We are committed in providing a first class service to all our clients, not just when you take out a policy, but throughout the life of your policy. We make sure that you have the support and advice needed when it comes to claiming.

Professional

We have been operating for over 30 years specialising in the insurance needs of healthcare providers and professionals. Our aim is to continue to develop, innovate, improve and reduce the cost of insurance for all our clients and future clients.