a. Proposer's full name:

c. Identify or C.R. number:

d. Telephone number:

Please indicate the cover and limit of Indemnity required:

Question 4:

a. At what medical school(s) 
did u qualify?:

Question 5:

What branch(es) of the medical profession are you qualified and licensed to practice? eg. General practice, Dentistry, Anaesthesiology, surgery, nursing, lab technician etc:

Question 6:

Question 7:

N.B: The answers to question 7 are for office use only as the policy will indemnify the proposer only. If it is your intention to cover the individual liability of any of the stated persons included in your answer you must advice your broker / consultant ITN and further forms will be provided for completion and quotation

If you are not self employed please indicate whether you are an employee of a government agency or the private health care sector (please give details) 

Question 9:

Please advise whether you have had medical professional liability insurance during the past 12 months. If yes, please give the name of the insurer.
Yes   No

Question 10:

Has any insurer ever cancelled, declined, refused to renew or only accepted on special terms your professional liability insurance? if Yes, please give details
Yes   No

Question 11:

Have you ever been convicted for an act  committed in violation of any law or ordinance (other than traffic offences) or been the subject of disciplinary proceedings or reprimand by any administrative agency or professional association? If Yes please give details
Yes   No

Question 12:

a. Have any claims or suits for negligence, error or omission been 
made against you?
Yes   No

b. Are you aware of any claims or suits for negligence, error or omission that may have been made against any of your partners, assistants, nurses or technicians?
Yes   No

c. Are you aware of any circumstances which may result in any 
such claim or suit being made?
Yes   No

If your answer to any of the above is Yes please give full details:

Declaration

I/WE HEREBY DECLARE that, to the best of my/our knowledge and belief, the above statements and particulars are complete and true and that I/we have not mis-stated or suppressed any materials facts. (A material is one which is likely to influence ITN underwriters acceptance or assessment of this proposal. If any doubt whether facts are material, they should be disclosed). Submitting this form does not bind the propser to completer the insurance, nor ITN or it's U/D to accept, but it is agreed that this form shall be the basis of the contract should a policy be issued.

Cover will be on claims made basis. This means that the policy will only respond to claims both made against you and notified to NOMINATE U/D through ITN during the period of insurance