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Medical Establishment FORM

Medical Establishment – Online Proposal Form

"*" indicates required fields

Step 1 of 4 - Application for Establishment Indemnity

0%

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 ( Chubb ) 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 will not covet you to the extent permitted by law , for such loss or damage.

The policy is underwritten by Chubb Insurance Malaysia Berhad, Registration Number: 197001000564 (“Chubb”). Chubb is licensed under the Financial Services Act 2013 and regulated by Bank Negara Malaysia. This policy is distributed by Tan Secretarial Services, a registered agent of Chubb, on the platform owned and operated by MedIndemnity.
- 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).

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

Website Address (if any)

Date of Practice entity established

DD slash MM slash YYYY

Type of Facility:

Indicate Nature of Practice Entity:

Indicate Number of Personnel:

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

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 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 Insurance Malaysia Berhad (“Chubb”) of any material alteration to those facts before completion of
the contract of insurance.
- I have read and agreed to the Declaration & Authorisation, Policy Wording and Product Disclosure Sheet. (note: please insert
hyperlink for all the documents)
- I hereby declare and agree for Chubb to deal with your personal data on this application to hold, use and disclose for the purpose
of processing this application and providing subsequent services for this and/or other insurance products and services, direct
marketing, and data matching as the Insurer may consider necessary in accordance with Chubb's Personal Data Protection Notice

Signature

GET YOUR MEDICAL MALPRACTICE INSURANCE WITH US

We promise to give our best services to you

CHUBB

Takaful

RHB

indemnity insurance executive lady post

OurGOOGLE TESTIMONIAL

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09/04/2022
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09/06/2022
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09/03/2022
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09/03/2022
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09/03/2022
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09/03/2022
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09/06/2022
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09/03/2022
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09/10/2022
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09/03/2022
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09/03/2022
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09/03/2022
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09/03/2022
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09/06/2022
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09/03/2022
The staff is very accommodating & providing a very fast Thanks a lot for the quick response for my inquiries.

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09/06/2022
Provided speedy service for the maid's insurance that I needed to purchase. Delivered online within the same day of application. 5 stars!

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09/10/2022
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09/11/2022
Easy. Responsive. All online.

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09/03/2022
Good job

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09/07/2022
Mr Tan is very efficient and very helpful. So easy to deal with. I received my indemnity insurance policy just one day after payment made 👍🏻 very trusted and reliable.

Anisah Abdul Latiff
09/07/2022

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We are the first of its kind one stop online shop in Malaysia specially catered for Medical Practitioner in Malaysia Since 2018.

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