Junior Doctor Application


The following must be read and all answers completed to enable us finalise your indemnity quotation, we will endeavour to respond in a prompt manner once we are in receipt of your application details.

This Application Form is designed for all junior doctor positions working in the private hospital sector in Ireland, the form 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 2 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.

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


Section 1 – Basic Details


Please confirm your current private hospital position*

If you have answer ‘Yes’ to any question below, please provide some additional information in Section 2 below.

Do you perform work outside the Republic of Ireland?*

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

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 2)*

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

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

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 IMC/GMC Fitness to Practice procedures?*

Please tick below at which private hospital(s) you work. If the entity is not listed, please tick “Other” and include name(s) of each:*

Section 2 – Additional Information

If you have answered ‘Yes’ to any question above, please provide some additional information in Section 2 below.

If you have answered ‘No’ type NA so the form can be submitted.

Section 3 – Declaration and Disclosure

Please tick to confirm that you have read and understand the Challenge Terms of Business document