DR.Cover Proposal Form

Professional Indemnity for Individual General Dentists & General Practitioners

IMPORTANT NOTICE

1. FOR NON-CONSUMER INSURANCE CONTRACTS (INSURANCE FOR PURPOSES RELATED TO THE INSURED’S TRADE, BUSINESS OR PROFESSION)

Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for a purpose related to your trade, business or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance.

The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us.

You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this Proposal Form is inaccurate or has changed.

2. This is a Proposal for a claims made and notified policy, it will only cover Claims which are first made against you and reported to the Insurer during the Policy Period. Defence Costs incurred will reduce the Limits of Liability available to pay Loss.

3. Every question must be answered in full, leaving no blank spaces. If the space provided is not sufficient to record a complete answer, please record the answer on a separate sheet of paper, sign, date and attach it to this form. This Proposal Form must be completed and signed by you. If the Form is completed by any other person, you must ensure that you are aware of all information stated herein.

4. The questions on this Proposal Form and any other details we specifically request relate to facts which we consider material to underwriting this insurance. However, because no list of questions can be exhaustive, please consider whether there is any other material information which is known to you which could influence our assessment and acceptance of this risk.

Please key in all your correct details for us to process your application.

Section 1: Applicant Details








     Government        Private Practice  



Section 2: Insurance History

1. Do you currently have OR have you ever had any medical professional indemnity insurance? If yes:
a. Name of Indemnity Provider/Insurer b. Limit of Indemnity c. Expiry Date
          
2. Have you ever been refused medical professional indemnity insurance before? If yes, please provide reasons.
          

Section 3: Notification History

CLAIM: Are you aware of any claim against you OR have you ever been involved, directly or indirectly in a claim, or suit arising from your practice? If YES, please give details
          
CIRCUMSTANCE: Are you aware of any circumstance or incident that may give rise to a claim against you? If yes, please give details
          
REGULATORY/DISCIPLINARY PROCEEDINGS: Were you ever subject to OR are you currently aware of any potential OR currently named/involved in any such proceedings?
          

Section 4: Area of Practice, Limit & Premium

General Dentist (GD)
Primary care to patients for diagnosis, treatment, management & overall coordination of services to meet patients’ oral health needs. These include: Fillings, Crowns, Veneers, Bridges, Gum Care & Preventive Education. The GD is NOT registered on any Specialist Register.
RM500,000 RM750,000 RM1,000,000
RM447.25 RM685.75 RM765.25
Government Dentist performing Locum
Maximum 20 hours per month in private sector. Cover includes regulatory & disciplinary proceedings for both government and locum work, AND private general dentist locum work. The Government Dentist NOT registered on any Specialist Register.
RM500,000 RM750,000 RM1,000,000
RM447.25 RM646.00 RM725.50
General Practitioner (GP)
Includes care of Patient & Pregnancy Management under 24 weeks gestation, excluding deliveries. GP is NOT registered on any Specialist Register.
RM500,000 RM750,000 RM1,000,000
RM447.25 RM685.75 RM765.25
General Practitioner with Obstetrics
For GPs who also provide care of Patient and Management of Pregnancy beyond 24 weeks gestation excluding deliveries. GP is NOT registered on any Specialist Register.
  RM1,000,000
  RM2,554.00
Government Doctor performing GP Locum
Maximum 20 hours per month in private sector. Cover includes regulatory inquiry for both government and locum work; and private GP locum work. Government Doctor is NOT registered on any Specialist Register.
RM500,000 RM750,000 RM1,000,000
RM447.25 RM646.00 RM725.50
Government Doctor’s Regulatory Cover
For Dentists, Doctors & Specialists in civil service only. Covers legal advice & representation at all regulatory hearings.
RM500,000
RM407.50

Section 5: Declaration and Signature

The undersigned, having made all necessary enquiries, declare that to the best of my knowledge and belief the statements in this proposal form and all attachments and schedules are true and complete; and immediate notice will be given to the Insurer should any of the above information alter between the date of this Proposal and the date of inception of the Policy.

Signing of this Proposal does not bind the Applicant or the Insurer to complete the insurance contract, but it is agreed that this Proposal shall be the basis of the contract should a Policy be issued, and it will be attached to and become part of the Policy. All written statements and materials furnished to the Insurer in conjunction with this Proposal are incorporated by reference into this Proposal and made a part hereof.

The Insurer and/or their representative are authorised to make any investigation and inquiry in connection with this application as is reasonable and necessary. Nothing contained in this Proposal shall constitute notification of a claim or potential claim.

I/We have fully read and understood the terms and conditions set out in the Insurer’s Personal Data Notice and consent to collection, use, disclosure, transfer, and processing of my / our Personal Information in accordance with the Personal Data Protection Act 2010. This includes personal data in the possession or under control of the Insurers, including personal data in the possession of organisations which the Insurer has engaged to collect, use, disclose or process personal data for the Insurer’s purposes.

I also declare that:
1.My medical license or my privileges at any hospital or institution have never been revoked, suspended, restricted, or placed on probation.
2.I have never been investigated by any licensing board, narcotics board, or other governmental or regulatory agency nor any fee or professional relations complaints have been filed against me with medical associations, hospitals, or licensing authorities.
3.I have not been indicted for, charged with, or convicted of, any act committed in violation of any law or ordinance other than traffic offenses
4.No allegation or claim has even been made against me regarding sexual harassment, sexual intimacy, exploitation, or sexual assault in the conduct of my practice or otherwise.
5.I have never intentionally altered or falsified patient records or knowingly made any change, correction, or addition without properly noting it as such.
6.I have never been diagnosed, or a mental or treated for alcoholism, drug addiction, any chemical dependency, or a mental or chronic physical illness.
7.With respect to my professional indemnity coverage, no insurance company or mutual has ever canceled, refused to renew, or restricted my coverage.
8.I am registered with the Malaysian Dental Council/Malaysian Medical Council and have a valid full registration number.
I am unable to make the above declaration for my professional history due to the reason(s) below:
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