Medical Malpractice Application Form

Medical Malpractice Application Form

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INTRODUCTION

The purpose of this application form is for us to find out more about you. Completion of this application form does not oblige either you or us to enter into a contract of insurance.

Following a reasonable search you must provide us with all information which may be material to cover we offer in a clear and accessible manner. Information is material if it would influence our decision whether to insure you, what cover we offer you or what premium we charge you. If you are in any doubt whether a fact or circumstance is material you should disclose it.

HOW TO COMPLETE THIS FORM

This form should be completed by the applicant who should make all the necessary enquires to enable our questions to be answered.

If you require extra space to answer the questions or provide any other material information, please use the additional information section at the back of the form. Once you have completed the form please return it directly to your insurance broker.
SECTION 1: PERSONAL DETAILS

1.1 Please provide the following details:

Title: *

Full name: *

Previous surname (if applicable):

Gender: *

Date of birth: * / DD / MM YYYY

Personal address: *

Postcode: *

Practice address: *

Postcode: *

Mobile telephone number: *

Practice telephone number: *

E-mail: *