Vicarious Proposal form

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?*

You and Your Practice
What is the total annual fee income derived from your dental activities?*
What date do you require the policy to incept/start?
DD slash MM slash YYYY
Do you require retrospective cover? If so please input the appropriate date
DD dot MM dot YYYY
Your Cover
What level of indemnity cover do you require?*
- £2,000,000
- £5,000,000
- £10,000,000
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
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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General Information