Dental Indemnity Prop 2023 - FTA - All Med Pro

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Insurance
About AMP
Client area
Education
- Past webinars
- Podcasts
Contact

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URL

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Membership Application

When is the start or renewal date of your indemnity policy?*

Full Name*

Title First Last

Phone*

Email*

Have you graduated within the last 5 years?*

Yes

No

Please confirm the following

Can 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?*

Total

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Limit of Indemnity

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Limit of Indemnity

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Limit of Indemnity

Claims and Conduct

Please 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 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 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 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 provide further details on the above*

5 - Have you ever been subject to any form of disciplinary action?*

Please 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 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 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 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 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 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 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 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 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 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 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 provide further details on the above including circumstances and dates*

Do you provide any prison service work?*

Yes

No

You and Your Practice

Address*

First Line of Address Town Postcode

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Is your correspondance address any different to the above?

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Address*

First Line of Address Town Postcode

Do you work for a Group or Corporate?*

Yes

No

Date of birth*

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?*

Will you be retiring in the next 5 years?*

What date are you looking to retire?

Are there or have there been any conditions or interruption attached to your GDC registration?*

Please provide additional information in respect to your GDC registration*

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Do you anticipate any material changes to the activities or the business in the next 12 months ?

Do you or your practice target or advertise to celebrities?

Please 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”?

If you know your retroactive date please provide

Has there ever been any gaps in your indemnity coverage?*

Please 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)?*

Letter of Good Standing

Please upload your letter of good standing if you have it to hand

Drop files here or

Max. file size: 10 MB.

Clinical Activities

Please 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?

Please provide further information

What % 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 Aesthetics

Please provide the annual number of anti wrinkle procedures

Please provide the annual number of collogen fillers

Please provide the annual number of facial peels

Please provide the annual number of other

Your Cover

What level of indemnity cover do you require?*

£2,000,000

£5,000,000

£10,000,000

Addendum

Please 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

Are you a member of the British Association of Oral and Maxillofacial surgeons?*

Are you a member of any other professional organisation?*

Do you perform reconstruction with axial and microvascular flaps?*

Do you personally administer general anaesthetics?*

Do you have the relevant post-graduate training and experience to administer general anaesthetics?*

Is the general anaesthetic administered by a dentist or medical practitioner with the appropriate post-graduate training and experience?*

Does 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?*

Does the Anaesthetist always have an assistant in support throughout the procedure and recovery?*

Is sedation ever administered?*

Is the IV sediation administered by you?*

What type of practitioner is the IV sedation administered by?*

General Anaesthetics

What type of sedation is administered?*

Intravenous

Inhalation / RA

Is the operating room equipped with continuously-acting monitoring devices and a defibrillator?*

Is there basic life support equipment set up in the operating room?*

Is the patient's full medical history always taken prior to administration of general anaesthetics/sedation?*

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?*

Where did you hear about us?*

Do you anticipate any material changes to the activities or the business in the next 12 months

Please provide further information

Declaration*

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 declaration

If you wish to supply additional information please provide below

Supporting Information

You may wish to supply supporting information such as your CPD log

Drop files here or

Max. file size: 10 MB.

Marketing Consent*

By ticking yes, you consent to receive email updates and other marketing communications from All Med Pro. We respect your privacy and will never share your information with third parties without your explicit consent. You can unsubscribe at any time by clicking the link provided in our emails. For more information on how we use and protect your data, please refer to our Privacy Policy.

Yes, I would like to receive email updates and marketing communications from All Med Pro.

No, I would not like to receive email updates and marketing communications from All Med Pro.

CONTACT US

Email:
info@allmed.co.uk
Enquiries:
0203 7576950
Address:
All Med Pro, Unit 5, Stanton Court, Stirling Road, Swindon SN3 4YH

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All Med Pro is a trading style of All Medical Professionals Limited who are authorised and regulated by the Financial Conduct Authority Number: 309653.
All Medical Professionals Limited registered in England number 4468555. Registered office: Unit 5, Stanton Court, Stirling Road, Swindon SN3 4YH
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