"*" indicates required fields Step 1 of 5 20% Membership ApplicationWhen is the start or renewal date of your indemnity policy?* DD slash MM slash YYYY Full Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Phone*Email* Have you graduated within the last 5 years?* Yes No Please confirm the followingCan you confirm that your primary activities as a dentist are dedicated to general oral health, encompassing essential areas such as endodontics, periodontal care, exodontia, and/or orthodontics and that you are spending less than 10% of your time engaging in implantology procedures and less than 30% of your time conducting cosmetic dentistry procedures. Yes No When did you graduate?*Within the last yearBetween 1 - 2 years agoBetween 2 -3 years agoBetween 3 - 4 years agoBetween 4 -5 years agoTotal HiddenLimit of Indemnity£10,000,000 (Claims Made)HiddenLimit of IndemnityRegulatory IncludedHiddenLimit of IndemnityRetroactive Date Inception Claims and ConductPlease read the following questions carefully and answer all of them fully and truthfully.1 - Have any complaints or claims been made, brought or threatened against you?*Please select Yes or NoYesNoPlease provide further details on the above including circumstances, dates and costs*2 - Are you aware of any acts, errors, omissions, incidents, events, circumstances or requests for notes which may give rise to a complaint or claim against you?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances, dates and costs*3 - Are you aware of any complaints, claims, acts, errors, omissions, incidents events or circumstances which may lead to an investigation, suspension, the imposition of conditions or restrictions on your registration or license to practice or your removal from a professional register or the removal of your license by a relevant registration body?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances, dates and costs*4 - Are you aware of any complaints, claims, acts, errors, omissions, incidents, events or circumstances which may lead to disciplinary actions or suspension of practice?* Please select Yes or NoYesNoPlease provide further details on the above*5 - Have you ever been subject to any form of disciplinary action?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates*6 - Have you ever had conditions to practice, been suspended or restricted from practice or dismissed from practice?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates*7 - Have you ever been subject to any form of investigation or adverse finding by a registration body or equivalent in any country?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates*8 - Have you ever been admitted to or sought treatment from any mental health or chemical / substance abuse programme?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates*9 - Have you ever been refused registration or license to practice or been erased from registration or had your license to practice suspended or removed by a registration body?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates*10 - Have you ever had any restrictions or conditions imposed on your registration or license to practice by a registration body?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates*11 - Have you ever been the subject of a Medical Defence Organisation’s adverse member procedure?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates*12 - Has any Medical Defence Organisation ever declined to offer you membership, terminated or restricted your membership or refused to renew your membership?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates*13 - Has any insurance indemnity provider ever declined to insure you, imposed special terms, cancelled or refused to renew your insurance?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates*14 - Are you being investigated, or have you ever been convicted of a criminal offence or received a formal police caution (not spent under the Rehabilitation of Offenders Act 1974) in any country?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates*15 - Have you ever suffered a loss of personal information as a result of a privacy breach?* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates*16 -Have you ever suffered a loss through the fraud or dishonesty of any other person(s) or are you aware of any matter which may lead to a claim against your employees such as staff, associates, dental nurses etc.* Please select Yes or NoYesNoPlease provide further details on the above including circumstances and dates* You and Your PracticeAddress* First Line of Address Town Postcode HiddenIs your correspondance address any different to the above?Please select Yes or NoYesNoHiddenAddress* First Line of Address Town Postcode Do you work for a Group or Corporate?* Yes No Date of birth* DD slash MM slash YYYY How many sessions per week do you work?*Please enter a number less than or equal to 14.What is the total annual fee income derived from your dental activities in the UK only?*What is your GDC registration number?*Are you a practice owner?*Please select Yes or NoYesNoWill you be retiring in the next 5 years?*Please select Yes or NoYesNoWhat date are you looking to retire? DD slash MM slash YYYY Are there or have there been any conditions or interruption attached to your GDC registration?*Please select Yes or NoYesNoPlease provide additional information in respect to your GDC registration*HiddenDo you anticipate any material changes to the activities or the business in the next 12 months ?NoYesDo you or your practice target or advertise to celebrities?NoYesPlease provide further information in respect to the type of celebrities you advertise or target?Please select your previous indemnity providers Dental Protection DDU MDDUS Hiscox InSync MIAB TDS (Taylor Defence Services) Towergate Other Provider No Previous Insurance Dental Protection*Please provide the dates that you were covered with Dental Protetcion DDU*Please provide the dates that you were covered with DDU MDDUS*Please provide the dates that you were covered with MDDUS Hiscox*Please provide the dates that you were covered with Hiscox InSync*Please provide the dates that you were covered with InSync MIAB*Please provide the dates that you were covered with MIAB Towergate*Please provide the dates that you were covered with Towergate MMI4U*Please provide the dates that you were covered with MMI4U DIA*Please provide the dates that you were covered with DIA Other Indemnity Provider*Please provide the dates that you were covered with other indemnity providers including the providers name What is your current renewal premium?* Has prior cover been on a “Claims Made Basis”?Please select Yes, No or UnknownYesNoUnknownIf you know your retroactive date please provide DD dot MM dot YYYY Has there ever been any gaps in your indemnity coverage?*Please select Yes or NoYesNoPlease provide full details of any gaps in coverage including dates*Do you have an updated claims history or letter of good standing from your previous indemnity provider(s)?*Please select Yes or NoYesNoLetter of Good StandingPlease upload your letter of good standing if you have it to hand Drop files here or Select files Max. file size: 64 MB. Clinical ActivitiesPlease select your clinical activities* General Dentistry Orthodontics Implantology Oral or Maxillofacial Surgery Facial Aesthetics Cosmetic Dentistry Surgical Periodontal Procedures What % of your time is spent on General Dentistry?*Please enter a number less than or equal to 100.What % of your time is spent on Orthodontics?*Please enter a number from 1 to 100.What % of your time is spent on Implantology?*Please enter a number from 1 to 100.What % of your implant work is restorative only?Please enter a number from 1 to 100.What % of implants involve sinus lifts?Please enter a number from 0 to 100.Please provide further information in respect to your their qualifications and experience in respect to sinus lifts.Do you perform zygomatic implants, implant osteotomy activities and/or pytergoid implants?YesNoPlease provide further informationWhat % of your time is spent on Facial Aesthetics?*Please enter a number from 1 to 100.What % of your time is spent on Oral or Maxillofacial Surgery?*Please enter a number from 1 to 100.Please may you clarify if the oral surgery you have selected relates to procedures such as exodontia, apicectomies or does it relate to complex oral procedures involving the intra-oral tissues, teeth and tooth carrying bones, i.e. mandible and maxilla?’What % of your time is spent on placement of veneers for elective/aesthetic only purposes?*Please enter a number from 1 to 100.What % of your time is spent on Surgical Periodontal Procedures?*Please enter a number from 1 to 100.Total Clincial Split Percentage %*Must equal 100% Please note: the total clinicial split percentage must equal 100%Are general anaesthetics ever administered? Yes No Do you personally administer General Aesthetic? Yes No Facial AestheticsPlease provide the annual number of anti wrinkle proceduresPlease provide the annual number of collogen fillersPlease provide the annual number of facial peelsPlease provide the annual number of otherYour CoverWhat level of indemnity cover do you require?* £2,000,000 £5,000,000 £10,000,000 AddendumPlease select any oral or maxillofacial surgery that you undertake.Dento-alveolar procedures - Surgical treatment of disorders of the teeth and their supporting hard and soft tissues. Apicectomies Exodontia (eg, wisdom teeth removal) Benign cyst removal Minor pre-prosthetic surgery Tooth transplantation Surgical removal of teeth Removal of impacted or ectopic teeth, including wisdom teeth Removal of developmental abnormalities of the teeth and jaws Benign jaw growth removal Dental implants (excluding sinus lifts or bone augmentation which involves the floor of the sinus, or extra-oral bone harvesting, all of which are regarded as maxillofacial procedures). Dental implants (including sinus lifts or bone augmentation which involves the floor of the sinus, or extra-oral bone harvesting, all of which are regarded as maxillofacial procedures). Trauma - Rhinoplasty, pinnaplasty, genioplasty Facial aesthetics - Rhinoplasty, pinnaplasty, genioplasty Cleft lip and palate Head and neck cancer Craniofacial surgery - Craniosynostoses, Craniofacial dysostoses, Orbital Skull base surgery Orthognathic surgery Select AllAre you a member of the British Association of Oral and Maxillofacial surgeons?*Please select Yes or NoYesNoAre you a member of any other professional organisation?*Please select Yes or NoYesNoDo you perform reconstruction with axial and microvascular flaps?*Please select Yes or NoYesNoDo you personally administer general anaesthetics?*Please select Yes or NoYesNoDo you have the relevant post-graduate training and experience to administer general anaesthetics?*Please select Yes or NoYesNoIs the general anaesthetic administered by a dentist or medical practitioner with the appropriate post-graduate training and experience?*Please select Yes or NoYesNoDoes the person administering the general anaesthetics (the Anaesthetist) always remain with the patient throughout the procedure and until the patient's protective reflexes have returned and the patient has gained control of their own airway?*Please select Yes or NoYesNoDoes the Anaesthetist always have an assistant in support throughout the procedure and recovery?*Please select Yes or NoYesNoIs sedation ever administered?*Please select Yes or NoYesNoIs the IV sediation administered by you?*Please select Yes or NoYesNoWhat type of practitioner is the IV sedation administered by?* General AnaestheticsWhat type of sedation is administered?* Intravenous Inhalation / RA Is the operating room equipped with continuously-acting monitoring devices and a defibrillator?*Please select Yes or NoYesNoIs there basic life support equipment set up in the operating room?*Please select Yes or NoYesNoIs the patient's full medical history always taken prior to administration of general anaesthetics/sedation?*Please select Yes or NoYesNo Do you have a membership with any of the following associations? ADI BACD BSDHT None Other Please advise which other association(s) youhave membership with Which of the following groups or corporates do you work for?*BUPADental BeautyDental PartnersDentexMyDentistPortmanOtherWhere did you hear about us?*Email/MailshotNetworking EventUK.DentalInstagramSocietyWorkshop/WebinarMagazineTwitterIntroducer ReferralADIBACDBSDHTColleague/FriendExhibitionsFacebookGoogle AdvertLinkedinOtherSearch EnginesDo you anticipate any material changes to the activities or the business in the next 12 monthsNoYesPlease provide further informationDeclaration*You declare and warrant that after enquiry all statements and particulars contained in this Proposal and addendum are true and that no information whatever has been withheld which might increase the risk of The Company or influence the acceptance of this Proposal and should the above particulars alter in any way you will advise The Company as soon as practicable. You understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of this Proposal may result in The Company refusing to provide indemnity or voiding the Policy in every respect. You hereby agree and accept that this Declaration shall be the basis of the contract between both parties if entered into. You confirm that as of the date hereof you have appointed All Med Pro as your exclusive Insurance Broker with respect to the above coverage. The appointment of All Med Pro rescinds all previous appointments and the authority contained herein shall remain in full force until cancelled in writing. I agree to the above declarationIf you wish to supply additional information please provide belowSupporting InformationYou may wish to supply supporting information such as your CPD log Drop files here or Select files Max. file size: 64 MB. EmailThis field is for validation purposes and should be left unchanged.