Private Practice SpecialistS

 

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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 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 7%
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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 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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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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 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 23%
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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 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 30%
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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 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 38%
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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 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)
Both
None
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Complete 46%
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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 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 53%
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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 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 61%
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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 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 69%
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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 Declaration
Profession
Anaesthetist
1. Do you provide chronic pain management?
Yes
No
None
1.1. If yes, please provide details:
2. Do you make use of your own anaesthetic-related informed consent form that patients sign?
Yes
No
None
Cardiologist
1. Do you perform any valve replacements or minimally invasive neurovascular interventions like endovascular treatment of aneurysms and strokes?
Yes
No
None
1.1. If yes, please provide details:
Neurologist
1. Do you perform minimally invasive neurovascular interventions like endovascular treatment of aneurysms and strokes?
Yes
No
None
1.1. If yes, please provide details:
Neurosurgeon

1. In terms of the number of surgical procedures you perform as primary surgeon, please indicate percentages for the following:

1.1. Cranial Procedures

Cranial Past Year % Numbers Only
Cranial Coming Year % Numbers Only

1.2. Spinal Procedures

Spinal Past Year % Numbers Only
Spinal Coming Year % Numbers Only

2. What percentage of patients under your care suffer from acute trauma-related injuries?

Acute Trauma Injuries % Numbers Only

2.1. What percentage of these relate to spinal trauma?

Spinal Trauma Injuries % Numbers Only
3. Do you perform corrective procedures for disorder of spinal curvature?
Yes
No
None
3.1. If yes, please specify type of procedures:

4. How many shunt-related surgeries do you perform on average per annum?

4.1. Adults

Adults Past Year Numbers Only
Adults Coming Year Numbers Only

4.2. Paediatrics

Paediatrics Past Year Numbers Only
Paediatrics Coming Year Numbers Only
Obstetrician/Gynaecologist
1. Do you provide obstetric services (defined as care of pregnant woman after 24 weeks gestation)?
Yes
No
None

If yes, please complete the following:

1.1. Number of deliveries per annum

Deliveries Past Year Numbers Only
Deliveries Coming Year Numbers Only

1.2. Percentage of deliveries that are performed by elective Caesarean section:

Caesarean % Numbers Only
1.3. What protocols do you follow for foetal monitoring during active labour?
1.4. What protocols do you follow for the use of oxytocic drugs?
1.5. Do you regularly oversee deliveries by midwives in an out-of-hospital setting?
Yes
No
None
1.5.1. If yes, please provide details:
2. Do you perform/report on detailed pregnancy scans, including nuchal translucency scans that are aimed at detecting foetal abnormalities?
Yes
No
None

If yes, please confirm the following:

2.1. Number of detailed scans conducted per annum

Scans Past Year Numbers Only
Scans Coming Year Numbers Only
2.2. Do you have Foetal Medicine Foundation Certification (or similar)?
Yes
No
None
2.2.1. If yes, please provide details:
2.3. Do you follow guidelines, published by SASOG Better OBS Programme, regarding foetal abnormality screening?
Yes
No
None

3. Please complete the following regarding gynaecological procedures.

 

Number of hysterectomies per annum as primary surgeon:

3. Private Patients

3.1. Abdominal

3.1.A. Abdominal Past Year Numbers Only
3.1.B. Abdominal Year Ahead Numbers Only

3.2. Vaginal

3.2.A. Vaginal Past Year Numbers Only
3.2.B. Abdominal Year Ahead Numbers Only

3.3. Laparoscopic

3.3.A. Laparoscopic Past Year Numbers Only
3.3.B. Laparoscopic Year Ahead Numbers Only

3. State Patients

3.4. Abdominal

3.4.A. Abdominal Past Year Numbers Only
3.4.B. Abdominal Year Ahead Numbers Only

3.5. Vaginal

3.5.A. Vaginal Past Year Numbers Only
3.5.B. Abdominal Year Ahead Numbers Only

3.6. Laparoscopic

3.6.A. Laparoscopic Past Year Numbers Only
3.6.B. Laparoscopic Year Ahead Numbers Only
3.7. If you perform any of laparoscopic procedures, have you received additional training/certification in this field (e.g. fellowship, Winners Programme)?
Yes
No
N/A
None
3.7.A. If yes, please provide details:
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Complete 76%
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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 Declaration

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Ophthalmologist
1. Does your practice perform eye care of premature infants at risk of/with established ROP?
Yes
No
None
2. Do you perform laser refractive surgery?
Yes
No
None

2.1. If yes, what is the average number of laser refractive surgeries you perform per annum?

2.1.A. Laser Refractive Past Year Numbers Only
2.1.B. Laser Refractive Coming Ahead Numbers Only
Orthopaedic Surgeon
1. Do you perform spinal procedures?
Yes
No
None
2. What percentage of patients under your care suffer from acute trauma-related injuries? % Numbers Only
2.1. What percentage of these relate to spinal trauma? % Numbers Only
3. Do you perform corrective procedures for disorders for spinal curvature?
Yes
No
None
3.1. If yes, please specify type of procedures:
Paediatrician
1. Do you treat infants in the first 28 days of life?
Yes
No
None

1.1. If yes, please complete the following:

1.1.A. Do you attend deliveries?
Yes
No
None
1.1.B. Do you look after neonates in the ICU?
Yes
No
None
1.1.C. Are there protocols in place in the neonatal ICU(s) in which you work?
Yes
No
None
Physician

1. Do you perform any of the following procedures?

1.1. Angiography
Yes
No
None
1.1.A. Angiography Details
1.2. Endoscopy
Yes
No
None
1.2.A. Endoscopy Details
1.3.Biopsies (other than skin)
Yes
No
None
1.3.A. Biopsies Details
2. Do you provide routine post-operative follow-up in the High Care and/or ICU for patients of your surgical colleagues (as opposed to consultations on referral due to specific post-operative complications)?
Yes
No
None
2.1. If yes, please provide details (e.g. field of surgical specialties for which this service is provided):
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Complete 84%
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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 Declaration

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Plastic & Reconstructive Surgeon

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?

1.1. Cosmetic % Numbers Only
1.2. Reconstructive % Numbers Only
2. Do you perform liposuction procedures in your rooms for patients with an ASA score of >1?
Yes
No
None

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).

3.1. Procedure
3.1.A. Number performed in past year Numbers Only
3.1.B. Number to be performed in coming year Numbers Only
3.2. Procedure
3.2.A. Number performed in past year Numbers Only
3.2.B. Number to be performed in coming year Numbers Only
3.3. Procedure
3.3.A. Number performed in past year Numbers Only
3.3.B. Number to be performed in coming year Numbers Only
3.4. Procedure
3.4.A. Number performed in past year Numbers Only
3.4.B. Number to be performed in coming year Numbers Only
Radiologist
1. Do you report on detailed pregnancy scans including nuchal translucency scans that are aimed at detecting foetal anomalies?
Yes
No
None
2. Do you perform interventional procedures?
Yes
No
None
2.1. If yes, please specify the types of procedures performed:
3. If yes to either of the two questions above, please specify any additional training received (e.g. fellowship):
Urologist
1. Do you perform laparoscopic surgery?
Yes
No
None

If yes, please complete the following:

1.1. How many of these procedures do you perform per annum as primary surgeon?

1.1.A. Primary Surgeon Past Year Numbers Only
1.1.B.Primary Surgeon Coming Year Numbers Only
1.2. Please specify any additional training in this field (e.g. fellowship):
2. Do you perform robotic surgery?
Yes
No
None

If yes, please complete the following:

2.1. How many of these procedures do you perform per annum as primary surgeon?

2.1.A. Primary Surgeon Past Year Numbers Only
2.1.B.Primary Surgeon Coming Year Numbers Only
2.2. Please specify any additional training in this field (e.g. fellowship):
Surgeon (General)
1. Do you perform bariatric surgery?
Yes
No
None

If yes, please complete the following:

1.1. Are you certified by a professional body to perform bariatric surgery?
Yes
No
None
1.1.A. If yes, by which organisation
1.2. Do you perform bariatric surgery in the context of a multidisciplinary team?
Yes
No
None
1.2.A. If yes, please provide details:

1.3. How many of these procedures do you perform per annum as primary surgeon? 

1.3.A. Primary Surgeon Past Year Numbers Only
1.3.B.Primary Surgeon Coming Year Numbers Only
2. Do you perform laparoscopic surgery?
Yes
No
None

If yes, please complete the following:

2.1. How many of these procedures do you perform per annum as primary surgeon? 

2.1.A. Primary Surgeon Past Year Numbers Only
2.1.B.Primary Surgeon Coming Year Numbers Only
2.2. Please specify any additional training in this field (e.g. fellowship):
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Complete 92%
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 Specialist Specific Questions 11 Specialist Specific Questions - Ophthalmologist, Orthopaedic Surgeon, Paediatrician, Physician 12 Specialist Specific Questions - Plastic & Reconstructive Surgeon, Radiologist, Urologist, Surgeon (General) 13 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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