IMPORTANT INFORMATION – PLEASE READ
This Application Form, which is designed for General Practitioners on the Medical Council register in Ireland, 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 or unsigned 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
An up to date copy of your CV must accompany the completed application form.
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.
Once completed, please sign and date the Declaration in Section 5 and return it to::
Challenge Insurance Brokers Limited
Tel: +353 1 8395942
Challenge House, 11 Burnell Square,
Mayne River Way, Malahide Road,
Should you have any questions, please contact Challenge Insurance Brokers Limited on +353 1 8395942
THE SIGNING OF THIS APPLICATION FORM DOES NOT BIND THE APPLICANT, OR INSURERS, TO COMPLETE A CONTRACT OF INSURANCE.