General Practitioner Application Form

Section 1 – Basic Details

Date of Birth

Gender
Male Female

Home Address (for all correspondence)

Email *

Practice Address

Medical Council Registration No.

Section 2 – Practice Profile

Please state the number of GP sessions undertaken per week, for which you require indemnity, performed in each of the following categories (A GP session is defined as clinic/period of 4 hours or less):

Split the total number of weekly sessions into the following categories (the total must match the number of sessions declared above)

Do you undertake telephone or video conferencing with any of your patients?
Yes
No

i) Are you engaged in the provision of medical support/services for professional sports clubs or associations?
Yes
No

ii) If Yes, do you need coverage for these services?
Yes
No

Do you undertake or take part in the administration of clinic trials?
Yes
No

As part of your role are you required to appraise and/or train your colleagues?
Yes
No

Do you plan to cease all practice within the next 5 years?
Yes
No

Is all work performed within the Republic of Ireland? (If No, Please provide additional details below)
Yes
No

If you have answered Yes to any of the questions (14-19), please provide full details below

Section 3 – Professional History

In which year did you qualify?

Are you qualified to practice as a GP in the Republic of Ireland?
Yes
No

Have you had medical indemnity in the Republic of Ireland before?
Yes
No

Please provide details of current insurance, if applicable.

Has your indemnity been continuous since qualification?
Yes
No

Has any application for this type of insurance cover or membership of any defence body ever been declined, cancelled or required special terms?
Yes
No

Have any claims for compensation been made against you for incidents or circumstances arising from public or private practice during the last 10 years? (If “Yes”, please provide the relevant date with brief details using additional space in Section 4)
Yes
No

Are you aware of any circumstances from your practice which may give rise to a claim against you?
Yes
No

Have all of the above circumstances been notified to your current indemnity provider or insurer?
Yes
No

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 Regulatory or Medical Council Fitness to Practice procedures?
Yes
No

Section 4 – Additional Information

Section 5 – 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.

Customer Signature