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APPLICATION FORM OF DENTIST APC
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VIDEO 1, 2, 3
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INDIVIDUAL
Chubb Brochure 2024
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MEDICAL ESTABLISHMENT
Chubb product disclosure sheet 2024
Chubb Elite policy Wording
Chubb Elite Application Form
Sykt Takaful policy wording
Sykt Takaful Application Form
ABOUT
ABOUT US
OUR TESTIMONIALS
DISCLAIMER
CONTACT US
APPLY NOW (INDEMNITY)
FAST TRACK ONLINE FORM
SPECIALIST ONLINE FORM
DENTIST ONLINE FORM
DOMESTIC MAID PA
MEDICAL ESTABLISHMENT ONLINE FORM
APPLY EMBEDDED PRODUCT
Solar PV All Risks Insurance
TRAVEL INSURANCE
CHUBB TRAVEL INSURANCE
TAKAFUL myMabrur
TAKAFUL myTravel PA
CHUBB CLINIC STAFF’S GROUP PA
PERSONAL ACCIDENT INSURANCE
TAKAFUL myMedik
RESOURCES
DOCTOR-A
Checklist Government Doctor Apply APC
MANUAL FOR RENEWING APC
HOW TO FIND OUT APPLICATION APC HAS BEEN QUERIED
HOW TO DO APC AMENDMENT
DENTIST-B
APPLICATION FORM OF DENTIST APC
DENTAL ACTS 2018
ENFORCEMENT DENTAL ACTS 2018
FOREIGN DOCTOR-C
HOW TO APPLY TEMPORARY PRACTICING CERTIFICATE
HOW TO APPLY TRANSLATION OF CERTIFICATE
HOW TO APPLY CERTIFICATE OF GOOD STANDING
MEDICAL STUDENT-D
GARIS PANDUAN PENGGUNAAN FASILITI KKM OLEH PELATIH AMAL
GARIS PANDUAN KKM FACILITIES- FOREIGN STUDENT
GARIS PANDUAN KKM FACILITIES- LOCAL STUDENT
WHY NEED INDEMNITY
VIDEO 1, 2, 3
FAQ
Tax Treatment Public Ruling by LHDN
FAQs ON PROFESSIONAL INDEMNITY
Tax Treatment of Specialist Doctor
POLICY WORDING & BROCHURE
INDIVIDUAL
Chubb Brochure 2024
Chubb Policy Wording
Chubb Product disclosure sheet 2024
Sykt Takaful policy wording
Sykt Takaful Application Form
Sykt Takaful Brochure
MEDICAL ESTABLISHMENT
Chubb product disclosure sheet 2024
Chubb Elite policy Wording
Chubb Elite Application Form
Sykt Takaful policy wording
Sykt Takaful Application Form
Medical Establishment
FORM
Medical Establishment – Online Proposal Form
"
*
" indicates required fields
Step
1
of
4
- Application for Establishment Indemnity
0%
Private Hospital
Public hospital
Clinic
Group Practice
Nursing Home
Rehabilitation Centre
Hospital
Laboratory
Pharmacy
Period of Insurance (From)
DD slash MM slash YYYY
Period of Insurance (To)
DD slash MM slash YYYY
Limit of Liability (Opt 1)
Limit of Liability (Opt 2)
Are you requesting cover for Fraud & Dishonesty?
*
Yes
No
Consent
*
IMPORTANT NOTICE TO THE APPLICANTS
*Your duty of disclosure*
- You have the duty to disclose to Chubb Insurance Malaysia Berhad or Syarikat Takaful Malaysia Berhad ( Chubb , us , we , our , STMB ) any matter that:(a) You know to be relevant to our decision on whether to accept the risks or not and the rates and terms to be applied; or (b) a reasonable person in circumstances could be expected to know to be relevant.
You have the duty to disclose those matters to Us before you renew, extend , vary or reinstate a contract of general insurance,
*Non-Disclosure*
- If you fail to comply with duty of disclosure, We May have the option of avoiding the contract of insurance from its beginning. If you non-disclosure is fraudulent, We may also have the right to keep the premium that you have paid.
*Change of Risks or circumstances*
- You should advice US as soon as practicable of any change to your normal business as disclosed in this application.
*Subrogation*
-Where you have agreed with another person or company, who would otherwise be liable to compensate you for any loss or damage which is covered by the policy , that you will not seek to recover such loss or damage from that person , Chubb or STMB will not covet you to the extent permitted by law , for such loss or damage.
The benefit(s) payable under eligible certificate/policy/product is(are) protected by PIDM up to limits. Please refer to
PIDM's TIPS brochure
or contact
Chubb Insurance Malaysia Berhad
or PIDM (visit:
www.pidm.gov.my
).The benefit(s) payable under eligible certificate/policy/product is(are) protected by PIDM up to limits. Please refer to
PIDM's TIPS brochure
or contact
Chubb Insurance Malaysia Berhad
or PIDM (visit:
www.pidm.gov.my
).
Please refer to the Policy Wording for the full details of benefits, exclusions, terms and conditions,. Click here for
Policy Wording
and
Product Disclosure Sheet.
Company Name
Registration Number (SSM)
Contact Person Name
First
Mobile Number
Email
Address of Office and/or Branch office
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Website Address (if any)
Date of Practice entity established
DD slash MM slash YYYY
Type of Facility:
Private Hospital
Public Hospital
Hospital - Other
Nursing Home
Miscellaneous Medical Facility (not operating as part of a hospital)
Indicate Nature of Practice Entity:
Joint Venture
For Profit
Not for Profit
Limited Liability company
Limited Partnership
Indicate Number of Personnel:
Principal
Partner
Director
Doctors (including locum doctors)
Surgeon
Pharmacist
Dentists
Nurses/ Healthcare assistance
Other staffs (please specify)
Number
Qualification of your principal/ partner /director? : Qualification / Years qualified / No of years as principal/partner/director(this practice and/or previous practice)
If you are sole Principal .what arrangement do you have in place to ensure business continuity when the principal is travelling, on leave ,ill away from office?
Which professional societies & associations are you , your principals partner and directors Members of ?
Is you Practice Entity duly Licence to practice at address mentioned ?
Do you ensure that all doctors providing medical services for or using the facilities of your firm are member of Medical Defense Union or Medical Protection Society or otherwise carry their own medical malpractice insurance cover?
If NO, are you requesting coverage for these doctors as part of your application?
Are you ISO 9001 certified? IF YES ,when was this achieved and for which activities ?
What is the total number of patients annually:
*
Outpatients
Inpatients
Number of outpatients in a year?
*
Number of inpatients in a year?
*
What are your activities are represented by each of the following of professional healthcare services:
Type of Services
Aged Care/Assisted Living
Cardiology
Communicable Disease/Tubercular
Dentistry
Dermatology
Drug/alcohol dependency
Ear/Nose /Troat
Elective Termination
Gastroenterology
General Practice/General Medicine
Gynaecological
In vitro fertilisation (IVF)
Obstetrics/maternity
Oncology
Ophthalmology(including LASIK & Laser)
Paediatrics
Pathology
Physiotherapy
Plastic surgery (elective cosmetic)
Plastic surgery (reconstructive)
Podiatry
Psychiatric
Radiography/medical imaging
Rehabilitation
Surgical
Traditional medicine
Do you engage in any other professional healthcare s services or business activities other than what is described in the section?
YES
NO
If Yes, please provide details
Are you or any of your Principals, Partners or Directors connected or associated with any other practice or business?
YES
NO
If Yes, please provide details
Details of Business:
When does your Financial Year end? (day/month)
What is your total turnover or fee income for
Past Year?
*
Current Year?
*
Estimate in ringgit (RM)
Coming Year?
*
Estimate in ringgit (RM)
Risk Management:
Do you maintain accurate & descriptive records of all medical services rendered ; have facilities for sterilization of instruments in accordance with guidelines; written procedure reporting of adverse events and consent obtained from each patient and documented medical records?
YES
NO
Insurance History:
Do you currently hold medical malpractice insurance?
YES
NO
If YES (above), please provide details. Period of Insurance: Insurer: Policy limit:
Have you ever had any application for medical malpractice insurance refused, or had any medical malpractice insurance coverage rescinded or cancelled?
YES
NO
If YES, please provide details on a separate sheet, noting the Section number.
Cyber and Privacy Infringement Liability (optional)
Do you have a formal policy to segment sensitive data, encrypt sensitive personal data [including Protected Information (PHI) and Electronic Medical Record (EMR)] anywhere that is stored, transmitted and/or on mobile devices,currently carry or are you in the process of applying for D&O or Cyber/Privacy Coverage, and Written Information Security Program (WISP)?
YES
NO
Have you taken all necessary steps to ensure compliance with the Personal Data Protection Act 2010 and /or any similar law or regulation in any other jurisdiction which governs the collection, use, processing, handling, storage, disclosure or transfer of personal/sensitive data?
YES
NO
Have you undergone an Information Security Audit?
YES
NO
If YES (above), what is the date? and is the result satisfactory?
Claims Experience
Claim History - Have any claims been made against you ; aware of any circumstances & allegations being made against you ; have you been the subject of disciplinary action by professional body ; have you had criminal charges brought against you ?
YES
NO
IF Yes please provide full details and status of each claim.
Additional Information to Send with Your Application:
Drop files here or
Select files
Max. file size: 128 MB.
Attach a copy of the following: Corporate profile, brochures, pamphlets, or other marketing material describing your operations and services Standard contracts or service agreements with clients or patients Resumes or CVs of all your Principals, Partners or Directors For new business only, your business plan with projections of business
Declaration
*
Declaration & Signature
- I have read and understood the importance notices contained in this application.
- I agree that this proposal together with any other information will form the basis of any contract of insurance.
- I acknowledge that if this application is accepted, the contract of insurance will be subject to terms and conditions as set out in the policy wording as issued or as otherwise specifically varied in writing by Chubb or STMB
- I declare after inquiry that the statement, particulars and information contained in this application and in any document accompanying this application are true and correct in every detail and that no other material facts have been misstated, suppress or omitted .
- I undertake to inform Chubb or STMB of any material alteration to those facts before completion of the contract of insurance.
- I understand the Chubb or STMB needs to deal with our personal data to administer our Policy and offer us insurance products and services . To achieve these purpose ,I allow Chubb or STMB to collect, use and disclose our personal data to selected third parties in or outside Malaysia, in accordance with Personal Data Protection Notice
Signature
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