If yes, please provide details of this cover in chronological order in the section below.
Please indicate any additional training received, including fellowships.
Where additional details are required, please supply these in the space provided at the end of this section.
Has any indemnity provider, in respect of the risks to which this application relates to, ever:
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.
Please indicate at which State hospital/clinic you work.
What is your % split in terms of hours spent between State and Private work?
Please indicate name(s) of hospital(s) where you treat patients in a private capacity.
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.
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. In terms of the number of surgical procedures you perform as primary surgeon, please indicate percentages for the following:
1.1. Cranial Procedures
1.2. Spinal Procedures
2. What percentage of patients under your care suffer from acute trauma-related injuries?
2.1. What percentage of these relate to spinal trauma?
4. How many shunt-related surgeries do you perform on average per annum?
4.1. Adults
4.2. Paediatrics
If yes, please complete the following:
1.1. Number of deliveries per annum
1.2. Percentage of deliveries that are performed by elective Caesarean section:
If yes, please confirm the following:
2.1. Number of detailed scans conducted per annum
3. Please complete the following regarding gynaecological procedures.
Number of hysterectomies per annum as primary surgeon:
3. Private Patients
3.1. Abdominal
3.2. Vaginal
3.3. Laparoscopic
3. State Patients
3.4. Abdominal
3.5. Vaginal
3.6. Laparoscopic
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2.1. If yes, what is the average number of laser refractive surgeries you perform per annum?
1.1. If yes, please complete the following:
1. Do you perform any of the following procedures?
1. In terms of the number of patients you treat, what percentage of your patients are anticipated to have predominantly cosmetic as opposed to reconstructive procedures?
3. Please list your most commonly performed procedures per annum performed in your rooms (excluding non-invasive cosmetic procedures like administration of Botox, and minor procedures like skin biopsies).
1.1. How many of these procedures do you perform per annum as primary surgeon?
2.1. How many of these procedures do you perform per annum as primary surgeon?
1.3. How many of these procedures do you perform per annum as primary surgeon?
I/We the undersigned duly authorised person(s) declare that:
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