Practitioner select insurance
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Personal Details

For any Compulsory fields marked * which do not apply to you, enter N/A.

Enter your full name *
Enter your email address *
Specify your date of birth *
Gender *
What is your contact phone number? *
Please advise the date that cover is required *
Choose the retroactive date *
Please advise which area of medicine you require indemnity for *
What is the amount of indemnity required? *
Please enter the date you started uk private practice *
Previous Cover

For any Compulsory fields marked * which do not apply to you, enter N/A.

Please enter the company name of your previous insurer *
Please enter the start date of your previous insurance *
Previous cover excess *
£
Previous cover premium *
£
Professional Details
In which country you received your qualification? *
What is the name of Medical or Dental School where you received your qualification ? *
Choose the year when you received your qualification *
What post graduate qualifications or trainings you received? *
Provide details of Professional Organisations of which you are a member *
Enter your GMC registration number? *
Choose the GMC registration date *
If applicable, please state your entry on the specialist register
Specify the specialist registration date
Admitting Rights at Private Hospital Groups

Other than HCA please list the private hospital groups you withwhom you have admitting rights. Select from the following list. If no relevant healthcare group is present or you only work in Independent private hospitals, please select "Other" *

Please specify other hospitals withwhom you have admitting rights.
Practice Profile
Please provide the address of your practice *
Please list any sub-specialisms or special interests you hold relevant to your private practice *
Are you employed by the NHS as a consultant in the area of medicine specified above? *
Please advise the names of the NHS Hospitals in which you are employed*
Work Breakdown

Please provide the % breakdown of your work between the following categories

%
%
%
Do you perform any surgical procedures, or consult on any conditions, in your private practice which you do NOT also perform/consult on in for the NHS?
Please specify:
Income

Please advise your Total Gross Annual Income from Private Practice

Last completed financial year
£
£
£
One year prior
£
£
£
Please provide an estimate of the number of Private practice surgical operations you undertake per annum (Including Endoscopies)
Split of Operations

Please provide a split, where applicable, of your Private Practice (%by number of sessions) between (the combined sum of all the fields must be 100%):

Consulting
%
%
%
Minor Surgery
%
%
%
Major Surgery
%
%
%
Sessions Per Week

How many sessions per week do you practice (1 session = 4 hours)

Consulting
Operating
Are you involved in clinical trials for which you require malpractice cover?
Please, provide full details:
Sport and Medicine Practice
Do you undertake any type of work for any professional sports club or for professional sports people including any pre-signing medical assessments?
Secify the sport and level
Please advise if there are any contracts in place and if so which clubs they are with
Travel
Are you involved in any activities that require you to travel outside the United Kingdom, the Channel Islands or the Isle of Man? (Please note that your PSI quote will NOT include cover for this work)
Please, provide the details:
Paediatric Work
Do you undertake any Paediatric work in the private sector?
Please advise what proportion(%) of your work this constitutes
%
Company Details
Do you operate as a Limited Company or similar joint venture?
Please advise the company name and number
Is this purely for fiscal purposes
Are any other medical practitioners associated with your Limited Company?
Please provide full details
Staff
Staff employ or engage any staff
Please give details of their job roles
Please provide further details
General Questions

Please provide the following details in relation to both NHS and Private Practice

Are you currently aware of, or have you ever been the aware of in the past, either wholly or in part, either in the UK or abroad, any of the following:

  • Any claim, circumstance, complaint or proceedings brought or threatened against you, or any incident which could lead to such a claim, circumstance, complaint or proceedings (this includes written or verbal complaints or expressions of dissatisfaction against you or connected with you).
  • Any investigation or adverse finding by any professional body, tribunal, regulatory or registration body.
  • Any disciplinary action.
  • Any conditions imposed on your practice or license to practice.
  • Any suspension or dismissal from practice, employment or registration.
  • Any criminal offence or formal police caution.
  • Any Medical Defence Organisation’s ‘adverse member procedure,
  • Declinature, termination, non-renewal or special conditions imposed by any insurer, mutual or Medical Defence Organisation.

If you have answered yes to any questions in the statements above, please give details
Please provide full details
Additional Information

Please provide any additional information on any other treatments offered, or any other information you believe will be relevant to your application:

Please provide any additional information
Please upload your claims history or any supporting documentation here.
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psi@integrogroup.com Tel: +44 (0)20 7444 6040 Mobile: +44 (0)7825 667 031 Contact person: Will Sheldon http://www.integrouk.com