Disclosure

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1. Disclosure

You must provide complete and accurate answers to the questions we ask you when you purchase a policy for the first time, make changes to your policy, or renew your policy. You must answer the questions posed by us honestly and with reasonable care.

Insurance is based on the information that you give to the insurer and if this information is wrong or incomplete, there may be adverse consequences: claims may not be paid in full or at all, your policy may have special terms imposed or be cancelled, your policy may be voided, and the premium paid may not be returned. If you are in doubt, please seek independent advice or contact us for clarification.

Please be aware that when providing information to the insurer, “material information” is information which would influence the judgement of a “prudent insurer” in fixing the premium or determining whether to cover the risk and we would ask you to disclose all material information pertaining to the questions posed in this proposal form.

Once the policy has come into effect, the policy itself contains specific terms requiring you to notify us in a timely fashion regarding any claims or potential claims. Once the policy has come into effect, you must cooperate with the insurer in the investigation of insured events, including by responding to reasonable requests for information in an honest and reasonably careful manner. Additionally, if, after a claim has been made under a policy, you become aware of information (including information that would otherwise be subject to privilege) that would either support or, as the case may be, would prejudice the validity of your claim, you shall be under a duty to disclose such information to the insurer.

The proposal must be completed by an authorised representative of the entity which is to be insured and all questions must be answered.

This is a proposal for a contract of insurance, in which ‘proposer’ or ‘you/your’ means the individual, company, partnership, limited liability partnership, organisation or association proposing cover.

This is a proposal form for a policy relating to claims made against the insured during the period of the policy only. The policy indemnifies the insured in respect of loss resulting from any potential claim, claim and/or inquiry arising as a consequence of any negligent act, error or omission by the insured on or after the retroactive date first notified to the insurer during the policy period.

2. Adequate Cover

You must ensure that you have adequate cover in place for the scope and nature of activities performed by all employees and volunteers at your entity.

3. Your Data

We will only use your information insofar as it is necessary to administer your insurance contract or in connection with a claim. Please see our Privacy Notice for more information on how we handle your data.

4. Formalities

Medisec Ireland CLG (Medisec) is a private company, limited by guarantee, having its registered office at 7 Hatch Street Lower, Dublin 2. Registered in Ireland No. 216570, Medisec Ireland CLG is regulated by the Central Bank of Ireland. The GP Entity Medical Malpractice product is distributed by Medisec as an intermediary and is underwritten by Berkshire Hathaway European Insurance Company DAC, trading as MedPro, which is authorised and regulated by the Central Bank of Ireland (C182407).

5. Additional Documents

• GP Entity Policy Brochure
• C3.A4 Medisec Terms of Business
• C3.A11 Medisec Data Protection Privacy Policy
• C3.A14 Medpro Data Privacy Notice
• C3.A5 Medpro Terms of Business
• GP Entity Policy IPID
• GP Entity Medical Malpractice Policy (Sample)

Please note, once you start this application process you will have to complete without leaving the page.

6. Confirmation

Dr Miss Mr Mrs Ms Prof -Select-

If different from your username.

v. What is the Retroactive Date?

if One or more of i-iv is yes, please provide details:

If yes: please provide details.

Please use this space to provide additional material information in support of the answers given on the proposal form. Please clearly show the question number to which the information relates

As the authorised representative of the entity submitting this application for insurance - I confirm that I have read and understood this notice

I declare that all the questions in this Proposal Form have been answered honestly and with reasonable care and that no information requested has been withheld or misrepresented. I understand that non-disclosure of material information could result in proportional remedies including a claim under the policy being declined or the policy being cancelled entirely and this might cause difficulty if I try to purchase insurance elsewhere.