Medical Malpractice Form

Medical Malpractice Form

    Please ensure that all information you provide is correct and that you answer all questions accurately. These details will form the basis of the insurance policy and any incorrect information could invalidate all or part of the insurance contract.

    Data Protection Statement

    You should understand that any information you have provided will be processed by the insurer in compliance with the provisions of the Data Protection Act 2018, for the purpose of providing insurance and handling claims or complaints, if any, which may necessitate providing such information to the other parties.

    Broker Details

    Client Details

    Contract Details

    WHO REQUIRES COVER - Please list all persons who will be performing treatments and their qualifications

    Clients History

    Client History

    Is there any other information we should take into account when assessing this proposal or any other information you need
    to declare as a material fact which may prejudice the Underwriter’s decision to quote? Please provide details below


    I confirm that I have read and agree all the below and confirm that all the information given in respect of this request for insurance is accurate and complete and represents a fair presentation of the risks.

    Usage of Information
    The information you provide will be used by the insurer to establish if it wants to take the risk and, if so, at what terms.

    Fair Presentation of the Risks
    You are required to disclose to the insurer information including material circumstances that fairly present the risks that would be insured should the insurer decide to take those risks.

    A fair presentation of the risks that, in addition to answering any questions asked of you, you must:

    • disclose to the insurer every material circumstance which you know or ought to know or, failing that, sufficient information to alert the insurer of the need to make further enquiries, and

    • make such disclosure in a reasonably clear and accessible manner, and

    • ensure that, in such disclosure, any material representation as to a matter of

    • fact is substantially correct, and

    • expectation or belief is made in good faith.

    A circumstance or representation is material if it would influence the insurer’s judgement (as a prudent underwriter) in determining whether to take the risk and, if so, on what terms. If you are in any doubt as to whether a circumstance or representation is material, then you should disclose it.

    Change in Risk Information

    The legal obligation of fair presentation applies if there is a change or variation in the risks that would be insured should the insurer decide to insure those risks and, if applicable, after you have accepted the insurer’s offer of insurance including the period those risks are insured under the policy.

    Disclosure & Accuracy of Information and Fair Presentation

    You must take care to give accurate and complete information and make a fair presentation of the risks when applying for insurance and, if you purchase the insurance offered, when making changes to it. If the information you have given proves to be inaccurate or incomplete and/or is not a fair presentation of the risks:

    Before you accept an offer of insurance, the insurer may:

    • Amend the terms of the offer, or

    • Withdraw the offer

    After you have accepted an offer of insurance, the insurer may:

    • Amend the terms of the insurance contract (policy) which, if applicable, may be applied as if they were in place prior to any claim where that claim was impacted by the inaccurate or incomplete information, or

    • If applicable, reduce the amount the insurer pays on a claim in proportion that the premium charged bears to the premium that the insurer would have charged you had the information not been inaccurate or incomplete, or

    • Treat the policy as if it had never existed, which means no claims will be paid under it and the premium paid will be returned to you. This will only be done if this insurance would not have been provided if the information given had not been inaccurate or incomplete.

    If the insurer establishes that you deliberately or recklessly provided false or misleading information in relation to this insurance:

    • Before you accept an offer of insurance, the insurer will treat the offer as if it never existed.

    • After you have accepted the offer, the insurer shall treat the policy as if it never existed, which means no claims will be paid under it and the insurer will not return any premium paid.

    Duty Of Disclosure

    IIGL would like to remind you of the duty of policyholders and intermediaries to pass on the Underwriter(s), all material information relating to the risk under consideration. “Material” in this context refers to all information which a prudent Underwriter (not necessarily the Underwriter in question), would wish to take account of when considering whether or not to accept the risk, and if so, upon what terms and at what price. Material information does not necessarily have to increase the risk. The duty of disclosure continues up until the Insurance has been concluded and resurrects” in the event of any amendment to the risk during the policy period or any extension/renewal. It may also be that the terms of the policy include specific ongoing disclosure conditions or warranties
    which effectively extend the duty of disclosure post inception of the policy. In the event that there is a breach of the duty of disclosure, the Underwriter has the right to avoid the Insurance from its commencement. Under such circumstances, the Underwriter(s) would be entitled to seek recovery of any claims already paid by them under the Insurance, although at the same time the Underwriter(s) would generally be obliged to return paid premium (in the absence of dishonest conduct).


    I/We declare and warrant that after enquiry all statements and particulars contained in this Proposal, and supplementary attachments/addenda, are true and that no information whatsoever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this Proposal and should the above particulars alter in any way I/We will advise the Underwriters as soon as possible. I/We understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of this Proposal may result in Underwriters refusing to provide Indemnity voiding the Policy in every acceptance and assessment of this Proposal may result in the Underwriters refusing to provide Indemnity voiding the Policy in every respect. I/We hereby agree and accept that this Declaration shall be the basis of the contract between both parties in entered into.