INTERNS & STUDENTS

 

Complete 0%
1 Personal Details 2 Quotation Details 3 Previous Insurance Cover 4 Professional Details 5 Professional Claims History 6 Practice Details 7 State Employment 8 Private Practice 9 Attestation 10 Interns & Students 11 Declaration
First Name *
Title *
ID Number Please enter ID number with no spaces
1 (Max. 13 Characters)
Email *
HPCSA Reg No
Practice Address
Surname *
Gender
Cell No *083 123 4567
VAT Number Please enter VAT number with no spaces
Do you provide chronic pain management?
Yes
No
None
If yes, please provide details of chronic pain management:
Do you make use of your own anaesthetic-related informed consent form that patients sign?
Yes
No
None
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Complete 9%
1 Personal Details 2 Quotation Details 3 Previous Insurance Cover 4 Professional Details 5 Professional Claims History 6 Practice Details 7 State Employment 8 Private Practice 9 Attestation 10 Interns & Students 11 Declaration
What type of quotation would you like?
Claims-made
Occurrence-based
Both
None
If you are currently on Claims-made cover, do you require retroactive cover?
Yes
No
None
If yes, please provide details of retroactive cover:
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Complete 18%
1 Personal Details 2 Quotation Details 3 Previous Insurance Cover 4 Professional Details 5 Professional Claims History 6 Practice Details 7 State Employment 8 Private Practice 9 Attestation 10 Interns & Students 11 Declaration
Have you had previous insurance cover for the type of insurance now being proposed?
Yes
No
None

If yes, please provide details of this cover in chronological order in the section below.

Insurer
Start Date
Type of Cover
Claims-Made (CM)
Occurrence-Based (OB)
None
End Date
If CM, please indicate original date of cover
What is your current premium per annum for PI cover?
Please attach a copy of your current PI schedule (Mandatory if requesting Retroactive Cover)
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Complete 27%
1 Personal Details 2 Quotation Details 3 Previous Insurance Cover 4 Professional Details 5 Professional Claims History 6 Practice Details 7 State Employment 8 Private Practice 9 Attestation 10 Interns & Students 11 Declaration

Qualification Details

Degree Obtained
Year Achieved
0 (Max. 4 Characters)
Name of University
Would you like to add another Qualification?
Yes
No
None
Degree Obtained
Year Achieved Numbers, No spaces
0 (Max. 4 Characters)
Name of University
Degree Obtained
Year Achieved Numbers, No spaces
0 (Max. 4 Characters)
Name of University
Degree Obtained
Year Achieved Numbers, No spaces
0 (Max. 4 Characters)
Name of University
Degree Obtained
Year Achieved Numbers, No spaces
0 (Max. 4 Characters)
Name of University

Additional Training & Affiliation

Please indicate any additional training received, including fellowships.

Institution
Year From Numbers, No spaces
0 (Max. 4 Characters)
Name of Programme
If you have advanced life support training and certification, what date is this renewable?
Certification received (e.g. ATLS, Fellowship Certification)

Professional Association or Society

Are you a member of any professional association or society?
Yes
No
None
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Complete 36%
1 Personal Details 2 Quotation Details 3 Previous Insurance Cover 4 Professional Details 5 Professional Claims History 6 Practice Details 7 State Employment 8 Private Practice 9 Attestation 10 Interns & Students 11 Declaration

Where additional details are required, please supply these in the space provided at the end of this section.

1. Has your professional status or professional role/job changed in the past 12 months?
Yes
No
None
2. Have you had any break in clinical practice over the past 5 years?
Yes
No
None
3. Has it ever been suggested by your employer, peers and/or third party that you be mentored and/or placed under supervision?
Yes
No
None
4. Have you ever been the subject of an inquiry by your employer, a non-regulatory professional body and/or a third party like a hospital or medical scheme? (e.g. following a patient complaint)
Yes
No
None
5. Have you ever had conditions imposed on your practice, been suspended or removed from the medical register due to a complaint, inquiry or investigation?
Yes
No
None
6. Declined an application, refused renewal or withdrawn cover?
Yes
No
None

Has any indemnity provider, in respect of the risks to which this application relates to, ever:

1. Imposed an extraordinary increase in premium and/or special conditions, including participation in risk management/educational program?
Yes
No
None
2. Declined an indemnity insurance claim by the insured or reduced its liability to pay an insurance claim in full (other than application of an excess)?
Yes
No
None
3. Have you ever received a regulatory complaint (e.g. HPCSA, OHSC) letter of demand or summons arising out of your professional practice?
Yes (Please specify details in the template provided in Annexure A)
No
None
Except for the cases that you have listed above, in the past five years, have you had a patient threaten legal action against you in your professional capacity, received a request for records, received a patient complaints/inquiry via a lawyer, been involved in an inquest or received a subpoena in a medical case?
Yes (Please specify details in the template provided in Annexure B)
No
None
If there are any other issues and/or concerns that you may reasonably consider to be important and that we should be aware of in recording your professional conduct, please share these below. These should include interactions with foreign regulatory authorities and healthcare systems.
Yes
No
None
Additional Details
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Complete 45%
1 Personal Details 2 Quotation Details 3 Previous Insurance Cover 4 Professional Details 5 Professional Claims History 6 Practice Details 7 State Employment 8 Private Practice 9 Attestation 10 Interns & Students 11 Declaration

Please provide us with your practice details for the period of insurance for which you are applying. For example, if you are currently a full-time employee in State, but are applying for insurance to cover you in private practice, answer questions in relation to your anticipated private practice.

Do you perform any work for the state?
Yes (You will be redirected to the “State Employment” section first)
No (You will be redirected to the “Private practice” only)
None
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Complete 54%
1 Personal Details 2 Quotation Details 3 Previous Insurance Cover 4 Professional Details 5 Professional Claims History 6 Practice Details 7 State Employment 8 Private Practice 9 Attestation 10 Interns & Students 11 Declaration

State Employment

Please indicate at which State hospital/clinic you work.

Please specify type of State employment:
Permanent Staff
Sessional Doctor
None
If you are a full-time State employee, please specify level of employment:
Head of Department
Consultant
Other
None
Please Specify Other Level of Employment
Name of Hospital/Clinic
Name of Hospital/Clinic
% of government work performed Numbers Only
% of government work performed Numbers Only

What is your % split in terms of hours spent between State and Private work?

% State Numbers Only
% Private Numbers Only
Are you planning to enter private practice full-time?
Yes
No
None
If yes, please provide the approximate date for private practice:
If you are recently qualified and are entering private practice for the first time, do you have assistance from a senior colleague for complex cases?
Yes
No
N/A
None
If yes, please provide details of assistance:
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Complete 63%
1 Personal Details 2 Quotation Details 3 Previous Insurance Cover 4 Professional Details 5 Professional Claims History 6 Practice Details 7 State Employment 8 Private Practice 9 Attestation 10 Interns & Students 11 Declaration
Please specify type of private practice. Tick all the boxes that are applicable.
Solus Private Practice
Private Practice Partnership
Private Group Practice
Associate
Locum (Clinical Work)
Salaried
None

Please indicate name(s) of hospital(s) where you treat patients in a private capacity.

Name of Hospital
Hospital Group
% of Your Private Patients Admitted Per Annum Numbers Only
Name of Hospital
Hospital Group
% of Your Private Patients Admitted Per Annum Numbers Only
Name of Hospital
Hospital Group
% of Your Private Patients Admitted Per Annum Numbers Only
Year of first seeing private patients as a specialist: Numbers Only
0 (Max. 4 Characters)

Practice Management

1. Will other staff in your practice (i.e., doctors, allied healthcare professionals and/or non-clinical staff) provide clinical services for which you would be vicariously responsible (e.g., nurse providing primary care services, beautician providing laser therapy, doctor employed in your practice)?
Yes
No
None
2. Do you employ locums?
Yes
No
None
2.1. Do you ensure that they are registered with the HPCSA?
Yes
No
None
2.2 Do you ensure that they carry indemnity cover?
Yes
No
None
3. Do you have colleagues that cover your practice when you are unavailable, including in the event of an emergency?
Yes
No
None
3.1. If yes, please provide their names and describe the business relationship (e.g. call roster, partnership):
3.2. If no, how do you ensure that your patients can access emergency care when you are not available?
3.3. If yes, do they carry indemnity cover?
Yes
No
Unsure
None
4. Do you see your in-hospital private patients on a daily basis?
Yes
No
None
4.1. If no, who provides this care?
5. Do you provide clinical services in private facilities as part of a State contract or alternative reimbursement model a like capitation agreement?
Yes
No
None
5.1. If yes, please provide details:

Patient Records

1. Do all your patients sign consent for consultations?
Yes
No
None
2. Do all your patients sign consent for surgical procedures, and/or in-theatre treatments?
Yes
No
None
3. Who in your practice takes informed consent from patients?
4. What is the current system you use for patient notes?
Hard Copy
Electronic
None
If electronic, please specify which system you use:
5. What are the procedures in place in your practice for dealing with patient complaints?
6. Do you comply with HPCSA’s guidelines on keeping patient records?
Yes
No
Unsure
None
7. Gross annual income in relation to government clinical professional services rendered: Numbers Only
8. Gross annual income in relation to private clinical professional services rendered: Numbers Only
9. Gross annual fees in relation to medico-legal services: Numbers Only
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Complete 72%
1 Personal Details 2 Quotation Details 3 Previous Insurance Cover 4 Professional Details 5 Professional Claims History 6 Practice Details 7 State Employment 8 Private Practice 9 Attestation 10 Interns & Students 11 Declaration

Please attest to the following statement. If you DISAGREE with any of the statements, please provide additional and complete information in the space provided at the end of this section.

1. I have never had my license to practice medicine and/or license to dispense medicines revoked or limited.
Agree
Disagree
None
2. I have never been charged or convicted of any criminal offence.
Agree
Disagree
None
3. I have never had any hospital privileges restricted, suspended, whether voluntarily or involuntarily, and I am not currently under investigation by any hospital.
Agree
Disagree
None
4. I do not perform any procedures that are outside the customary scope of practice for which I am applying for coverage.
Agree
Disagree
None
5. I have never been part of forensic audit by a medical scheme and I have never had a payment by a medical scheme reversed for reasons of alleged over-billing/over-servicing.
Agree
Disagree
None
6. I have never been declared an “impaired physician” by the HPCSA.
Agree
Disagree
None

If retro-active cover is required, please also attest to the following and provide additional and complete information at the end of the section.

I have notified my current/previous insurer(s) of all the following for the time period for which backdated cover is being requested:

1. Requests for records (for reasons other than processing of RAF or COID applications) from a patient, family member/custodian of a patient, or an attorney.
Agree
Disagree
N/A
None
2. Letter from an attorney regarding diagnosis, treatments and/or advice that I provided to a patient.
Agree
Disagree
N/A
None
3. Threat of a legal, including HPCSA, claim against me in my professional capacity, even if such action is without merit.
Agree
Disagree
N/A
None
4. Any unexplained and/or unusual adverse clinical outcome.
Agree
Disagree
N/A
None
5. An awareness of a failing or short-coming of my work, or real doubt about my clinical performance or a party for whom I am responsible in the course of my professional activities, which could give rise to a third-party loss.
Agree
Disagree
N/A
None
6. HPCSA complaints, even if you deem these to be without merit.
Agree
Disagree
N/A
None
Additional Attestation Information:
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Complete 81%
1 Personal Details 2 Quotation Details 3 Previous Insurance Cover 4 Professional Details 5 Professional Claims History 6 Practice Details 7 State Employment 8 Private Practice 9 Attestation 10 Interns & Students 11 Declaration

Interns & Students

International Patients

1. Do you regularly treat international patients who have travelled to receive treatment from you?
Yes
No
None
1.1. If yes, how many on average in the past 12 months?
2. List all the mechanisms used, if any, to attract international patients.
3. Will you regularly repatriate patients?
Yes
No
None

Scope of Practice

1. Please confirm the % breakdown of time spent on professional activities offered by you for which you require cover:

1.1. Activity % Numbers only
1.1. Activity % Numbers only
1.2. Activity % Numbers only
1.5. Activity % Numbers only
1.3. Activity % Numbers only
1.6. Activity % Numbers only

Total must equal 100%

2. On average, how many patients will you consult per month? Numbers only
3. Will you conduct participate in clinical trials?
Yes
No
None
4. Do you perform Radiofrequency Ablation?
Yes
No
None
4.1. If Yes, please provide a copy of your certificate of training and/or list of courses attended.
4.2. Upload Certificate of Training. jpg, png, pdf, doc, docx
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5. Do you provide chronic pain management?
Yes
No
None
5.1. If Yes, please provide us with details regarding the chronic pain management provided.
6. Do you perform general/spinal/caudal anaesthesia?
Yes
No
None

6.1. Please provide details of anaesthetic experience in the public sector.

6.1.A. Public Sector Position Held
6.1.B. Public Sector Position Held
6.1.C. Public Sector Position Held
6.1.A. Year From
6.1.B. Year From
6.1.C. Year From
6.1.A. Year To
6.1.B. Year To
6.1.C. Year To
6.2. Please specify from which year you have been performing anaesthetics in the private sector.
6.3. Do you perform general anaesthesia on children under age 1 year or on pregnant women?
Yes
No
None
6.4. Average number of patients treated per annum Numbers Only
7. Do you perform conscious sedation other than in an emergency unit or hospital theatre?
Yes
No
None
7.1. Do you perform conscious sedation in your rooms or another practitioner’s rooms?
Yes
No
None
7.2. Do you administer the conscious sedation drugs and also perform the conscious sedation procedure?
Yes
No
None
7.2.A. If yes, what type of practitioner assists you (e.g. nurse)?
7.3. For which type of procedures do you perform conscious sedation?
7.4. What drug regimen(s) do you use?
7.5. Do you have emergency protocols in place?
Yes
No
None
7.6. Do you keep a logbook of all cases?
Yes
No
None
7.7. Are the facilities in which you carry out conscious sedation accredited by SOPOSA or COHSASA?
Yes
No
None
7.8. Are these facilities equipped with the necessary equipment and drugs required in an emergency?
Yes
No
None
7.9. Is resuscitation equipment checked and maintained regularly?
Yes
No
None
7.11. Do you perform conscious sedation on children under age 1 year or on pregnant women?
Yes
No
None
7.12. Average number of patients treated per annum Numbers Only
7.10.A. If no, in what proximity is the closest ICU?
7.13. Please submit copies of informed consent forms and other documentation such as sedation monitoring chart and post-discharge patient information leaflet that you may be using where you perform conscious sedation.
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7.10. Is the facility where sedation takes place within a hospital building with an ICU?
Yes
No
None
8. Do you provide emergency services in a private casualty/trauma unit?
Yes
No
None

8.1. Please provide details of casualty/trauma unit experience in the public sector.

8.1.A. Public Sector Position Held
8.1.B. Public Sector Position Held
8.1.C. Public Sector Position Held
8.1.A. Year From
8.1.B. Year From
8.1.C. Year From
8.1.A. Year To
8.1.B. Year To
8.1.C. Year To
8.2. Please specify from which year you have been performing emergency services in the private sector.
8.3. Average number of hours per week that emergency services are provided. Numbers Only
9. Do you perform aesthetic/cosmetic procedures e.g., Botox, non-permanent fillers, chemical facial peels, collagen injections, hair transplants without flap surgery, laser therapy, thread lifting, liposuction or sclerotherapy?
Yes
No
None
9.1.A. Procedure
9.1.B. % of time spent Numbers Only
9.1.C. No. of years performed Numbers Only
9.1.D. Training & certification incl. years obtained
9.2.A. Procedure
9.2.B. % of time spent Numbers Only
9.2.C. No. of years performed Numbers Only
9.2.D. Training & certification incl. years obtained
9.3.A. Procedure
9.3.B. % of time spent Numbers Only
9.3.C. No. of years performed Numbers Only
9.3.D. Training & certification incl. years obtained
10. Do you perform circumcisions and/or terminations of pregnancy?
Yes
No
None
10.1. If yes, please specify
11. Do you perform surgical procedures typically performed within an operating theatre as the primary surgeon e.g., tonsillectomy, appendectomy, vasectomy?
Yes
No
None

If yes, please specify the types of procedures and approximate number per month.

11.1.A. Procedure
11.2.A. Procedure
11.3.A. Procedure
11.1.B. Approx. number per month Numbers Only
11.2.B. Approx. number per month Numbers Only
11.3.B. Approx. number per month Numbers Only
12. Do you provide surgical assistance?
Yes
No
None

If yes, please complete the following:

12.1. Do you assist with obstetric, neurosurgical and spinal or bariatric cases?
Yes
No
None
12.1.A. If yes, please specify
12.2. How many surgeons do you assist regularly? Numbers Only
12.3. Is your assistance limited to holding instruments in theatre?
Yes
No
None
12.3.A. If no, please provide as much detail as possible (e.g. provide post-operative care, perform surgical closure).
13. Do you perform planned deliveries?
Yes
No
None

If yes, please complete the following:

13.1.A. Public Sector Position Held
13.2.A. Public Sector Position Held
13.3.A. Public Sector Position Held
13.1.B. Year From
13.2.B. Year From
13.3.B. Year From
13.1.C. Year To
13.2.C. Year To
13.3.C. Year To
13.4. Please specify from which year you have been performing deliveries in the private sector.
13.5. Average number of deliveries per annum Numbers Only
13.6. Percentage of deliveries by elective Caesarean Section Numbers Only
14. Do you perform basic pregnancy scans?
Yes
No
None
14.1. Do you have an informed consent form that specifies intentions and limitations of the scan?
Yes
No
None
14.2. Please provide details of experience and training.
15. Do you offer foetal abnormality screening to patients?
Yes
No
None
15.1. If yes, please provide details.
16. Other than clinical services described in your answers, are there any other professional activities like, for example, voluntary work or paid advisory services to companies, for which you may require assistance should an adverse event arise from such activity?
Yes
No
None
16.1. If yes, please provide details.
17. Do you practice telemedicine/virtual medicine, defined as the remote diagnosis and treatment of new patients by means of telecommunications technology?
Yes
No
None
17.1. If yes, please provide details.
18. Will you do procedures that may be deemed to be experimental (e.g. not generally performed by your colleagues for reasons of limited evidence)?
Yes
No
None
18.1. If yes, please provide details.
19. Do you have a field of special interest within your area of practice?
Yes
No
None
19.1. If yes, please provide details.
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Complete 90%
1 Personal Details 2 Quotation Details 3 Previous Insurance Cover 4 Professional Details 5 Professional Claims History 6 Practice Details 7 State Employment 8 Private Practice 9 Attestation 10 Interns & Students 11 Declaration

I/We the undersigned duly authorised person(s) declare that:

  1. I am/we are authorised by each of the Insureds to sign this Proposal Form.
  2. The above statements are correct, true and complete.
  3. No information material to this Proposal Form has been withheld.
  4. I/we have read the important facts which you have put before me/us and I/we understand the advice given in relation to the duty of disclosure.
  5. I/we have diligently made all necessary and detailed enquiries in order to comply with the duty of disclosure.
  6. Apart from what is disclosed in this document, I/we are not aware of any request for records being made by a patient, family member of a patient, or an attorney nor have I/we received a letter from an attorney regarding treatment which was provided to a patient.
  7. Apart from what is disclosed in this document, I/we are not aware of any circumstance which might reasonably lead to a claim or suit being lodged against me, regardless of whether I/we view that suit to be without merit.
  8. I/we understand that no insurance is in force until such time as the Insurer has confirmed acceptance of the proposed insurance.
  9. I/we undertake to inform the Insurer of any material alteration to these facts occurring before completion of the contract of insurance.
  10. I/we acknowledge that the Insurer relies on the information and representations in this Proposal Form and otherwise made by me/us in relation to this insurance.
  11. I/we acknowledge that the signing of this proposal form binds neither myself to accept the subsequent quote, nor does it bind the Insurer to accept the proposal. It is agreed that all written statements and attachments furnished to the Insurer in conjunction with this proposal are hereby incorporated by reference into this proposal and made part thereof.
  12. Except where indicated to the contrary, I/we understand that any statement made in this Proposal Form will be treated by the Insurer as a statement made by all persons to be insured.
I Agree*
Yes
First Name *
Surname *
Date *
Submit
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