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PROPOSAL FORM

Step 1 of 5 - You/Your Organisation

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Your/Your Organisation

Name(Required)

Title First Name Last Name

Date of Birth(Required)

Day

Month

Year

Main Address(Required)

Street Address City Post Code Country

Email(Required)

Phone(Required)

What is your GDC Registration Number?(Required)

What was the year that you graduated in dentistry?(Required)

What post graduate qualifications have you attained?

Click + to add another entry

Clinical Activities

Apart from General Dentistry & IV sedation, please confirm other activities you carry out below:

Clinical Activities

Clear Aligner Orthodontics

Fixed Orthodontics

Facial aesthetics

Implantology

Sinus lifts

Intra oral bone grafts

Extra oral bone grafts

Zygomatic implants

Clear Aligner Orthodontics (% of time spend)(Required)

Please enter a number from 0 to 100.

Fixed Orthodontics (% of time spend)(Required)

Please enter a number from 0 to 100.

Implantology (% of time spent)(Required)

Please enter a number from 0 to 100.

How many implants have you placed over the past year?(Required)

Please state the number of implants you expect to place this year.(Required)

What proportion of your implant work is restorative (by number of implants):(Required)

Please advise what additional training you have undertaken in relation to implant work and when this was undertaken:(Required)

Sinus lifts (% of time spent)(Required)

Please enter a number from 0 to 100.

What proportion of your implant work involves sinus lifts (by number of implants):(Required)

Intra oral bone grafts (% of time spent)(Required)

Please enter a number from 0 to 100.

Extra oral bone grafts (% of time spent)(Required)

Please enter a number from 0 to 100.

Zygomatic implants (% of time spent)(Required)

Please enter a number from 0 to 100.

Do you have peer support available to discuss unusual or complex cases which are at the limit of your expertise/experience?(Required)

Yes

No

If yes, please explain what you would do if presented with such a case(Required)

How many locations do you operate from?(Required)

Are you included on any specialist registers?(Required)

Yes

No

Please provide full details:

Are you a practice owner?(Required)

Yes

No

Practice Name(Required)

First

Practice Address(Required)

Street Address City Post Code Country

Do you/your practice operate via a limited company?(Required)

Yes

No

Please provide the name of your limited company

Please state whether you require cover for any acts, errors or omissions committed by any Dentist or Dental Care Practitioner working on your behalf:(Required)

Yes

No

Please state your practice's annual turnover in respect of the last complete financial year(Required)

Please state your practice's annual turnover in respect of the current financial year(Required)

Please provide an estimate of your practice's annual turnover for the next financial year(Required)

Do you limit your practice to a particular interest or field?(Required)

Yes

No

Do you have any dentists with Special Interests?(Required)

Yes

No

If yes, please give specific details (e.g how many and what the Special Interests are):(Required)

Please provide a full breakdown for the number of staff that work at your practice and state whether they are employed, self-employed or agency(Required)

This includes number of registered dentists, therapists, CDTs, dental technicians, registered dental nurses, trainee dental nurses, admin staff, foundation dentists and any others

Please provide a full breakdown of the percentage of gross turnover generated from general dental work:(Required)

Please provide a full breakdown of the percentage of gross turnover generated from hygienist services:(Required)

Please provide a full breakdown of the percentage of gross turnover generated from implant work:(Required)

Please provide a full breakdown of the percentage of gross turnover generated from orthodontic work:(Required)

Please provide a full breakdown of the percentage of gross turnover generated from facial aesthetics:(Required)

Please provide a full breakdown of the percentage of gross turnover generated from dental technician services:(Required)

Please provide a full breakdown of the percentage of gross turnover generated from the sale of products:(Required)

Please provide a full breakdown of the percentage of gross turnover generated from specialist dental work:(Required)

Are you planning to retire in the next 5 years?(Required)

Yes

No

If Yes, can you provide an anticipated date for retirement?

Cover Requirements

When do you need cover to start?(Required)

Day

Month

Year

How many sessions do you work per week?(Required)

Limit of indemnity required(Required)

£1,000,000

£2,000,000

£3,000,000

£5,000,000

£10,000,000

Who is your current indemnity with?(Required)

Please provide details of who your indemnity providers have been over the last 5 years.(Required)

How much are you currently paying for your indemnity?(Required)

Is the previous policy on a claims made basis?(Required)

Yes

No

Unsure

If yes, what is the retroactive date?

A retroactive date is the date from which you have held uninterrupted professional indemnity insurance cover (even if you changed insurer during this time) or a date in the past from which your insurer has agreed to cover you.

Day

Month

Year

Has any insurer/indemnifier ever cancelled, declined/refused to renew, or only accepted the risk at special terms?(Required)

Yes

No

Unsure

If yes, please give details:(Required)

Claims

After full enquiry, are you aware of any incidents or circumstances which may lead to any claim, complaint or allegation of negligence?(Required)

Yes

No

After full enquiry, are you aware of any incidents or circumstances which may lead to disciplinary action, conditions, restrictions or suspension from practice?(Required)

Yes

No

Have you ever been subject to any form of disciplinary action or investigation by a regulator, employer or principal?(Required)

Yes

No

Have you ever been subject to any adverse findings, conditions, suspension or erasure by a regulator, registration body or equivalent?(Required)

Yes

No

Have you ever been subject to been subject to any conditions or suspension to practice by any employer or principal?(Required)

Yes

No

Have you ever been subject to any claim, complaint or allegation of negligence (even if the outcome was in your favour)?(Required)

Yes

No

Please note that "complaint" includes but is not limited to any verbal or written complaint or any expression of dissatisfaction

Have you been convicted of or charged with any offence, other than a motoring offence or conviction spent for the purposes of the Rehabilitation of Offenders Act 1974?(Required)

Yes

No

If you answered Yes to any of the above, please provide full details:(Required)

Supplementary Practice Owner's Questionnaire

The following questions apply to both yourself as well as any person working on your behalf

After full enquiry, has any claim, complaint or allegation of negligence been made during the last 10 years (even if there was a favourable outcome)?(Required)

Yes

No

Please note that "complaint" includes but is not limited to any verbal or written complaint or any expression of dissatisfaction.

After full enquiry, has there been any form of disciplinary action or investigation for professional misconduct?(Required)

Yes

No

After full enquiry, has any statutory sanction ever been brought?(Required)

Yes

No

After full enquiry, have you or anyone working on your behalf ever been subject to any adverse findings, conditions, suspension or erasure by a regulator, registration body or equivalent?(Required)

Yes

No

Is there any incident or circumstance which may lead to any claim, complaint or allegation of negligence or disciplinary action or investigation?(Required)

Yes

No

Please note that "complaint" includes but is not limited to any verbal or written complaint or any expression of dissatisfaction.

Has there been a loss of data that has resulted in a privacy breach?(Required)

Yes

No

Has any insurer or indemnity provider ever declined to insure you or anyone working on your behalf, imposed any special terms, cancelled or declined to renew an insurance policy or membership of a Dental Defence Organisation?(Required)

Yes

No

If the answer to any of the above is yes, then please provide full details including an explanation of the background of events, all relevant dates, the status of the claims or circumstances, the maximum amount involved or claimed and any reserves or payments made.(Required)

Material information

Please provide us with details of any additional information which may be relevant to our consideration of your proposal for insurance. If you have any doubt over whether something is relevant, please let us have details.

Is there anything else that you would like to tell us about you or your business?(Required)

Yes

No

If Yes, please provide this below:

Please enter the amount of income you would like to insure, based on your earnings from last year (in £)(Required)

Finally, could you tell us how you heard about us?(Required)

Referral code (optional)

Declaration(Required)

By signing this proposal form, you consent to us using the information we may hold about you or others related to your policy for the purposes of providing insurance and handling claims, if any, and to process sensitive personal information about you or others related to your policy where this is necessary (for example health information or criminal convictions). This may mean that the insurer has to give some details to third parties involved in providing insurance cover. These may include insurance carriers third-party claims adjustors, fraud detection and prevention services, third party service providers, reinsurance companies, insurer tracing offices and insurance regulatory authorities. Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use by the insurer as set out above. The information provided will be treated in confidence and in compliance with all relevant regulation and legislation. You or others related to your policy may have the right to apply for a copy of this information (for which the insurer may charge a small fee) and to have any inaccuracies corrected. For training and quality control purposes, telephone calls may be monitored or recorded.

I/we confirm that the information given in this proposal form is correct, accurate and complete and I have made a fair presentation of the risk.

Signature

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LET’S TALK

We can arrange meetings in person, online or over the phone. Get in touch using one of the options below.

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Insurify Ltd trading as Dental Defence League is an appointed representative of Medical Insurance Consultants Ltd which is authorised and regulated by the Financial Conduct Authority and is entered on the Financial Services Register https://register.fca.org.uk/s/ under reference 309026. Please note: The Dental Defence League Student Membership is not FCA regulated.

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