Application Form

Period of Insurance (From)

Period of Insurance (To)

Name

IC Number

Limit of Liability (Opt 1)

Limit of Liability (Opt 2)

Date of Birth

Phone Number

Email

Primary Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Qualification

Institution

Degree/Qualification

Years Obtained

Details of Registration

Licensing Body

Registration Number

Registration Date

Please list any medical societies & Association member of:

Please provide total income (per annum)

Please provide total number of patient (per annum)

Do you currently hold any Medical malpractice insurance

Yes
No

Period of insurance

Insurer

Policy Limit

Do you provide healthcare services in your host country only?

Yes
No

Information

Details of Healthcare Services

Risks management:

Do you maintain accurate and descriptive records of all medical services and equipment

Yes
No

Do you have facilities for sterilization of instruments in accordance with relevantly guidelines

Yes
No

Do you have written procedure for reporting of incidents and adverse events

Yes
No

Is informed consent obtained from each patient and documented in their medical records

Yes
No

Claims Experience

Have any claims ever been made or lawsuits been brought against you

Yes
No

Are you aware of any errors,omission , offenses which might result in a claim being made against you ?

Yes
No

Have you been the subject of disciplinary action or investigation by any authority or regulator or professional body ?

Yes
No

Have you ever been the subject of criminal charges brought against you ?( disregard any traffic or minor motor vehicle licensing offenses

Yes
No

Qualification

Details of Registration

Risks management:

Claims Experience

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