ORGANISATION - CLINIC/HOSPITAL

 

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1 Your Organisation 2 Experience & Qualifications - Step 1 3 Experience & Qualifications - Step 2 4 Experience & Qualifications - Step 3 5 Step 4 6 Declaration

Your Organisation

1. Name of Insured *
2. Contact Person *
3. Practice Address
Suburb
City
Province/State/Region
Physical Code
5. Email *
7. Company Registration No
6. Cell No *011 000 1234
8. VAT No Numbers only
9. Location of branch offices
10. Have you ever carried out medical services under a different name?
Yes
No
None
10.1. If Yes, please provide details:
11. Do you have any subsidiary companies that you require cover for?
Yes
No
None
12. Please give full description of your business activities for which cover is required.
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Complete 16%
1 Your Organisation 2 Experience & Qualifications - Step 1 3 Experience & Qualifications - Step 2 4 Experience & Qualifications - Step 3 5 Step 4 6 Declaration

Experience & Qualifications

1. Please state the owner(s) names and details of their experience and qualifications.

1.1. Name
1.1. Shareholding % Numbers Only
1.1. Experience/Qualifications
1.2. Name
1.2. Shareholding % Numbers Only
1.2. Experience/Qualifications
1.3. Name
1.3. Shareholding % Numbers Only
1.3. Experience/Qualifications
1.4. Name
1.4. Shareholding % Numbers Only
1.4. Experience/Qualifications

2. Revenue

2.1. When is your financial year end?
2.2. What are your estimated fees for the coming 12 months? Numbers Only
2.3. Please provide gross revenue (VAT Inclusive) received. Numbers Only

2.4. Gross Revenue - Hospital/Clinic:

2.4. Last Financial Year Numbers Only
2.4. Previous Financial Year Numbers Only
2.4. Estimated Forth Numbers Only

2.5. Gross Revenue - Rentals/Leases:

2.5. Last Financial Year Numbers Only
2.5. Previous Financial Year Numbers Only
2.5. Estimated Forth Numbers Only

2.6. Gross Revenue - Medical Procedures/Treatments:

2.6. Last Financial Year Numbers Only
2.6. Previous Financial Year Numbers Only
2.6. Estimated Forth Numbers Only

2.7. Gross Revenue - Pharmacies:

2.7. Last Financial Year Numbers Only
2.7. Previous Financial Year Numbers Only
2.7. Estimated Forth Numbers Only

2.8. Gross Revenue - Any Other Source:

2.8. Last Financial Year Numbers Only
2.8. Previous Financial Year Numbers Only
2.8. Estimated Forth Numbers Only
3. Do your activities involve a joint venture with any other company, partnership, individual or other professional grouping?
Yes
No
None
3.1. If Yes, please provide details:
4. Will the activities involve new or incoming partners that are involved in your activities during the next 12 months.
Yes
No
None
4.1. If Yes, please provide details:
5. Are public funds, private funds or endowments used to maintain the Insured, either in whole or in part1/
Yes
No
None
5.1. If Yes, please provide details:
6. Are any beds or services available to the community on a charitable basis?
Yes
No
None
6.1. If Yes, please state percentage. Numbers Only

7. Please state number of beds maintained.

7.1. Full pay beds or part-pay beds (other than bassinets for maternity cases). Numbers Only
7.2. Charity beds (other than bassinets). Numbers Only
7.3. Maternity beds (i.e. bassinets). Numbers Only

8. Number of babies delivered on an annual basis.

8.1. Does the Insured have a neo-natal ward. Numbers Only
8.2. Number of bassinets/cribs. Numbers Only
8.3. Ratio of nurses to babies. Numbers Only
9. Number of operating theatres. Numbers Only
10. Average annual bed occupancy. (Calculated by noting the occupancy at any specific day of each month and dividing the aggregate total of 12 months by 12.) Numbers Only
11. In respect of medical services at the address specified above, are you in possession of the registered licenses and or registrations from the applicable regulatory body, or as required by law.
Yes
No
None
11.1. If No, please provide details:
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Complete 33%
1 Your Organisation 2 Experience & Qualifications - Step 1 3 Experience & Qualifications - Step 2 4 Experience & Qualifications - Step 3 5 Step 4 6 Declaration

Experience & Qualifications

12. Please state number of employees in each of the following classifications.

12.1. Anaesthesiology

12.1. # of Employees Numbers Only
12.1. # Self-Employed Numbers Only
12.1. # of Years Practising Numbers Only

12.2. Cardiac/Thoracis/Vascular Surgery

12.2. # of Employees Numbers Only
12.2. # Self-Employed Numbers Only
12.2. # of Years Practising Numbers Only

12.3. Dental Surgery/Maxilla-Facial

12.3. # of Employees Numbers Only
12.3. # Self-Employed Numbers Only
12.3. # of Years Practising Numbers Only

12.4. Dentist/Orthodontist

12.4. # of Employees Numbers Only
12.4. # Self-Employed Numbers Only
12.4. # of Years Practising Numbers Only

12.5. Dermatology

12.5. # of Employees Numbers Only
12.5. # Self-Employed Numbers Only
12.5. # of Years Practising Numbers Only

12.6. ENT

12.6. # of Employees Numbers Only
12.6. # Self-Employed Numbers Only
12.6. # of Years Practising Numbers Only

12.7. General Practitioner

12.7. # of Employees Numbers Only
12.7. # Self-Employed Numbers Only
12.7. # of Years Practising Numbers Only

12.8. General Surgery

12.8. # of Employees Numbers Only
12.8. # Self-Employed Numbers Only
12.8. # of Years Practising Numbers Only

12.9. Gynaecologists

12.9. # of Employees Numbers Only
12.9. # Self-Employed Numbers Only
12.9. # of Years Practising Numbers Only

12.10. Internal Medicine

12.10. # of Employees Numbers Only
12.10. # Self-Employed Numbers Only
12.10. # of Years Practising Numbers Only

12.11. Lab/Pathology Technicians

12.11. # of Employees Numbers Only
12.11. # Self-Employed Numbers Only
12.11. # of Years Practising Numbers Only

12.12. Neonatology

12.12. # of Employees Numbers Only
12.12. # Self-Employed Numbers Only
12.12. # of Years Practising Numbers Only

12.13. Neurology

12.13. # of Employees Numbers Only
12.13. # Self-Employed Numbers Only
12.13. # of Years Practising Numbers Only

12.14. Nurses - Sports Scientist

12.14. # of Employees Numbers Only
12.14. # Self-Employed Numbers Only
12.14. # of Years Practising Numbers Only

12.15. Nurses - Enrolled Nurses

12.15. # of Employees Numbers Only
12.15. # Self-Employed Numbers Only
12.15. # of Years Practising Numbers Only

12.16. Nurses - Matrons

12.16. # of Employees Numbers Only
12.16. # Self-Employed Numbers Only
12.16. # of Years Practising Numbers Only

12.17. Nurses - Midwives

12.17. # of Employees Numbers Only
12.17. # Self-Employed Numbers Only
12.17. # of Years Practising Numbers Only

12.18. Nurses - Nurse Anaesthetist

12.18. # of Employees Numbers Only
12.18. # Self-Employed Numbers Only
12.18. # of Years Practising Numbers Only

12.19. Nurses - Registered Nurses

12.19. # of Employees Numbers Only
12.19. # Self-Employed Numbers Only
12.19. # of Years Practising Numbers Only

12.20. Nurses - Student Nurse

12.20. # of Employees Numbers Only
12.20. # Self-Employed Numbers Only
12.20. # of Years Practising Numbers Only

12.21. Nurses - Auxiliaries Nurses (Qualified)

12.21. # of Employees Numbers Only
12.21. # Self-Employed Numbers Only
12.21. # of Years Practising Numbers Only

12.22. Care Workers

12.22. # of Employees Numbers Only
12.22. # Self-Employed Numbers Only
12.22. # of Years Practising Numbers Only

12.23. Obstetrics

12.23. # of Employees Numbers Only
12.23. # Self-Employed Numbers Only
12.23. # of Years Practising Numbers Only

12.24. Orthopaedics

12.24. # of Employees Numbers Only
12.24. # Self-Employed Numbers Only
12.24. # of Years Practising Numbers Only

12.25. Paediatrics

12.25. # of Employees Numbers Only
12.25. # Self-Employed Numbers Only
12.25. # of Years Practising Numbers Only

12.26. Paramedics

12.26. # of Employees Numbers Only
12.26. # Self-Employed Numbers Only
12.26. # of Years Practising Numbers Only

12.27. Pharmacists

12.27. # of Employees Numbers Only
12.27. # Self-Employed Numbers Only
12.27. # of Years Practising Numbers Only

12.28. Plastic Surgery

12.28. # of Employees Numbers Only
12.28. # Self-Employed Numbers Only
12.28. # of Years Practising Numbers Only

12.29. Radiology

12.29. # of Employees Numbers Only
12.29. # Self-Employed Numbers Only
12.29. # of Years Practising Numbers Only

12.30. Residential Medical Officers

12.30. # of Employees Numbers Only
12.30. # Self-Employed Numbers Only
12.30. # of Years Practising Numbers Only

12.31. Urology

12.31. # of Employees Numbers Only
12.31. # Self-Employed Numbers Only
12.31. # of Years Practising Numbers Only

12.32. Directors/Partners/Principals

12.32. # of Employees Numbers Only
12.32. # Self-Employed Numbers Only
12.32. # of Years Practising Numbers Only

12.33. Administration

12.33. # of Employees Numbers Only
12.33. # Self-Employed Numbers Only
12.33. # of Years Practising Numbers Only

12.34. Other

12.34. # of Employees Numbers Only
12.34. # Self-Employed Numbers Only
12.34. # of Years Practising Numbers Only

12.35. TOTAL

12.35. TOTAL # of Employees Numbers Only
12.35. TOTAL # Self-Employed Numbers Only
12.35. TOTAL # of Years Practising Numbers Only

13.    Please state the approximate division of your patients between:

13.1. Major Surgery
13.2. Minor Surgery
13.3. Cosmetic Surgery
13.4. Orthopaedics
13.5. Obstetric
13.6. Ophthalmology
13.7. Prosthetic Fitment
13.8. ENT
13.9. Dental/Maxillofacial
13.10. Accident & Emergency
13.11. Drug/Alcoholic
13.12. Communicable Infectious Diseases
13.13. Frail Care/Aged
13.14. Insanity/Psychiatric
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Complete 50%
1 Your Organisation 2 Experience & Qualifications - Step 1 3 Experience & Qualifications - Step 2 4 Experience & Qualifications - Step 3 5 Step 4 6 Declaration

Experience & Qualifications

14. Which associations, professional bodies or self-regulatory organisations is the Insured a member of or registered with:
15. Are you a member of a group of hospitals?
Yes
No
None
15.1. If Yes, please provide details:
16. Are you affiliated to any other medical interest?
Yes
No
None
16.1. If Yes, please provide details:

17. Please state number of X-Ray machines/M.R.I./C.A.T. or similar scanners owned or operated, and whether they are used for:

17.1. Diagnosis Numbers Only
17.2. Treatment Numbers Only
18. Do you administer Radium, or any other forms of radio-active treatment?
Yes
No
None
18.1. If Yes, please provide details:
19. Is any telemedicine undertaken by the Insured?
Yes
No
None
19.1. If Yes, please provide details:
20. Do you operate any road or air ambulance services?
Yes
No
None
20.1. If Yes, please provide details:
21. Do you use nurse anaesthetists?
Yes
No
None
22. Do you ensure that they carry individual medical malpractice cover?
Yes
No
None
23. Do you have a fully qualified anaesthesiologist available on site at all times?
Yes
No
None
24. Do you have a Blood Bank?
Yes
No
None
25. Do you provide fertility treatments/drugs/contraceptives?
Yes
No
None

26. Clinical Trials

26.1. Do you undertake clinical trials or provide facilities at which clinical trials can be undertaken?
Yes
No
None
26.1.A. If Yes, please state all active trials during the last 12 months.
26.2. Are the trials being conducted at your premises approved by the Medical Council of South Africa?
Yes
No
None
26.3. Have the trials been registered with The South African Clinical Trial Register (SANCTR)?
Yes
No
None
27. Do you undertake surgical procedures, including transplants?
Yes
No
None
27.1. If Yes, please provide details:
28. Are accurate and descriptive records of all medical services and procedures kept.
Yes
No
None
29. How are they stored, where and for how long?
30. Do you undertake staff training?
Yes
No
None
30.1. If Yes, please provide details:
31. Do you undertake to ensure that trainees carry out their duties under proper supervision?
Yes
No
None
32. Do you maintain Clinics (e.g. Mammograms, antenatal Clinics, Renal Clinics etc)?
Yes
No
None
32.1. Type
32.2. Free patients/full pay/part pay
32.3. Number of Clinics Numbers Only
32.4. Number of Doctors Numbers Only
32.5. Number of Nurses Numbers Only
32.6. Estimated total number of patients per year. Numbers Only
32.7. Estimated number of foreign patients treated per year. Numbers Only
33. Do your staff receive any formal medical malpractice risk management training?
Yes
No
None
34. Are all buildings owned or used by you in good state and regularly maintained/repaired?
Yes
No
None

35. Are the following regularly checked, serviced and repaired by fully qualified contractors?

35.1. Air Conditioning Units
Yes
No
None
35.2. Electricity Generators (including any emergency backup generators)
Yes
No
None
35.3. Escalators
Yes
No
None
35.4. Heating Systems and Boilers
Yes
No
None
35.5. Hoists
Yes
No
None
35.6. Incinerators
Yes
No
None
35.7. Lifts
Yes
No
None
35.8. Water Tanks
Yes
No
None
35.9. Sprinkler System
Yes
No
None
36. Please provide details of any subcontracted functions or facilities.
37. Do you ensure subcontractors carry their own insurance?
Yes
No
None

38. Are there facilities for safe collection, storage and disposed of (in accordance with current guidelines/legislation).

38.1. Sharps
Yes
No
None
38.2. Dressings, clinical and surgical waste, etc.
Yes
No
None

39. Do you ensure that the following are safely disposed of (in accordance with current guidelines/legislation).

39.1. Blood and blood products
Yes
No
None
39.2. All other medical waste
Yes
No
None
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Complete 66%
1 Your Organisation 2 Experience & Qualifications - Step 1 3 Experience & Qualifications - Step 2 4 Experience & Qualifications - Step 3 5 Step 4 6 Declaration

General Information

1. List all circumstances/complaints/claims of professional negligence, error or omission or public liability that have been made against the Practice or any of the present or past Principals or employees, whether insured or not, in the past 5 years.
2. Are any of the Principals or Employees of the Practice, after enquiry, aware of any circumstances that may give rise to a claim for professional negligence, errors or omissions or public liability.
Yes
No
None
2.1. If Yes, please provide details:
3. Has any application for insurance of this nature (made on behalf of the Practice your predecessors in business or by any of the present Partners) ever been declined, cancelled or has renewal been refused or have special terms been imposed.
Yes
No
None
3.1. If Yes, please provide details:

Quote Request

1. Limit of Indemnity (Rand) Numbers in Rands
2. Limit of Indemnity (Rand) Numbers in Rands
3. Limit of Indemnity (Rand) Numbers in Rands

Previous Insurance Cover

1. 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.

1.1. Insurer
1.1. Start Date
1.1. End Date
1.1. Limit of Insurance Numbers in Rands
1.2. Insurer
1.2. Start Date
1.2. End Date
1.2. Limit of Insurance Numbers in Rands
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Complete 83%
1 Your Organisation 2 Experience & Qualifications - Step 1 3 Experience & Qualifications - Step 2 4 Experience & Qualifications - Step 3 5 Step 4 6 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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