PDI - Protrusive Offer

Comments
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General Information
Is your renewal due within the next 60 days?
What is your renewal date?
DD slash MM slash YYYY
What month is your indemnity due?
Full Name*
Title First Last
Profession*
Phone*
Email*
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

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

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.

I agree to the above declaration
What is your current renewal premium?*
If you wish to supply additional information please provide below
Supporting Information
You may wish to supply supporting information such as your CPD log
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- 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.

Dental Indemnity PDI - Protrusive Offer

Step 1 of 5

General Information

Claims and Conduct

You and Your Practice

Clinical Activities

Facial Aesthetics

Your Cover

Addendum

General Anaesthetics