Dental Practitioner Application Form

IMPORTANT INFORMATION – PLEASE READ

This Application Form, which is designed for practitioners on the Dental Council Register, must be signed by the Applicant. It is the duty of the Applicant to disclose all material facts. For the purpose of this Application Form, a material fact shall be deemed to be one that would be likely to influence the judgement of a prudent insurer in fixing the premium or determining whether to underwrite the risk. Each section of this Application Form must be completed in full. Incomplete forms will not be accepted. Should there be insufficient room on any part of the Application Form to record all necessary details, please use the space provided in Section 5 with reference to the appropriate question.

Failure to disclose full and accurate details may entitle Insurers to void your contract of insurance and will mean that you are not entitled to any benefits of, nor make any claims against, your policy. It is the responsibility of the Applicant to notify any future change of address or any changes in their professional circumstances.

Limit of Indemnity

€1,000,000 Any One Claim and €2,000,000 in the Annual Aggregate
These limits of indemnity operate in cognisance of the HSE medical card scheme limit requirements.

Policy Excess

The excess on this policy is €0 (NIL) each and every claim

Should you have any questions, please contact Challenge Insurance Brokers Limited on +353 1 8395942.

THE SUBMITTING OF THIS APPLICATION FORM DOES NOT BIND THE APPLICANT, OR INSURERS, TO COMPLETE A CONTRACT OF INSURANCE.

Tick Yes to confirm you have read and understood the IMPORTANT INFORMATION.*
Yes

* denotes a compulsory field

Section 1 – Personal Details

Name of the Insured Dental Practitioner including Trading and Company Name *

Date of Birth *

Home Address *

Practice Address (List all if more than one)*

Mobile Number *

Work Phone Number

Email Address *

Practice Web Address

Dental Council Registration Number *

Section 2 – Practice Profile

Type of Dentist *

General Dental Practitioner

Hospital / Health Board Dental Surgeon

Specialist / Consultant Practitioner

Other

Please provide a summary of procedures performed: *

If you are an Oral Surgeon, please provide an approximate no. of surgeries per year ? *

Do you perform Private maxillofacial surgery other than routine oral (dento-alveolar) surgery? *

Yes

Is all work performed within the Republic of Ireland? *

Yes

Do you plan to cease all practice within the next 5 years? *

Yes

Please state the approximate percentage split between each of the following categories:

Private Practice % (incl Medical Card Scheme income) *

Public Practice % (directly for HSE) *

Section 3 – Professional History

What year did you begin private practice *

Please provide details of current insurance, if applicable.

Current Indemnity Provider *
DPL

Other

Year First Joined *

Subscription Renewal Date *

Current Subscription*

Has your indemnity been continuous since qualification? *

Yes

Has any application for this type of insurance cover or membership of any defence body ever been declined, cancelled or required special terms? *

Yes

Have any claims for compensation been made against you for incidents or circumstances arising from public or private practice during the last 10 years? *

Yes

Are you aware of any circumstances, from your public or private practice, which may give rise to a claim against you? *

Yes

Have all of the circumstances listed above been notified to your current indemnity provider or insurer? *

Yes

Have you ever been convicted of any criminal offence (other than minor driving offences), and/or subject to professional disciplinary proceedings by your Employer and/or Dental Council Fitness to Practice procedures? *

Yes

Section 4 – Financial Information

a. Please confirm your gross annual income from your private practice, excluding both dento-legal and income from public work
Note: Income from Medical Card Scheme is to be included

for the past accounting year?*

projected for current accounting year? *

b. What is your gross annual income from dento-legal work only in your private practice?

for the past accounting year?*

projected for current accounting year?*

c. Do you provide your services or bill your patients via a Limited Company, or a similar joint venture? *

Yes

Section 5 – Additional Information

Additional Information

Section 6 – Declaration and Disclosure

I declare and warrant that, after enquiry, all statements and declarations contained in the completed Application Form, together with any and all other information, statements and declarations made to Insurers, or their representatives, by or on behalf of the Insured, whether written or oral, are true and that no information whatsoever has been withheld which might increase the risk to Insurers or influence the acceptance of this Application Form. Should the above statements and declarations alter in any way, I will advise Challenge as soon as practicable. I understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of this Application Form may result in the refusal to provide indemnity or voiding the policy in every respect.

I hereby accept that this Declaration shall be the basis of the contract between both parties if entered into. By signing this document, I authorise Challenge to release information to necessary third parties and give permission for Challenge to use my email address, as provided in Section 1, to send their quotations or correspondence.

Please Tick Yes below to confirm you have read and understood the Declaration and Disclosure. *
Yes

Please Tick Yes below to confirm you have read and understood our Terms of Business *
Yes

Dated on *

Full Name of Signatory *

Prove you're not a robot *