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Medical Malpractice & Public Liability Insurance for HPA Members Application Form

Date: 16/10/2019

About You
State full name of the individual or name of the organisation to be insured.
£
If the name of the Proposer is a Private Limited Company, Partnership or other organisation please state:
If No, how many others are engaged and in what capacity?
If other people are engaged or employed you must consider separate Employers Liability Insurance (details available on
request)
Please Select Your Occupation
Activities to be Insured
This insurance is designed to cover the scope of Healthcare Practice which you are appropriately qualified to undertake.
Will you be involved in any of the following?
If you have answered Yes to undertaking Independent Prescribing, please confirm
If Yes please state:
Limits of Indemnity
Please select the limit of indemnity required.
£
Sub‐limits may apply in some circumstances, please refer to the quotation for details.

The above limits also apply to the total for all claims under the policy in any period of insurance.
Policy Start Date
The policy cannot start until this proposal has been approved and the quotation accepted.
Disclosure of Material Facts
Declarations
Your Duty of Disclosure
See attached leaflet on the changes introduced by the “Insurance Act 2015”. It is your duty to ensure sufficient information about your business is provided to insurers that enables them to understand the risks to be insured, or to make further enquiries. You may need to consult with others within your business who may also have relevant knowledge that should be declared to insurers. This duty continues throughout the lifetime of the policy when any change in circumstances should be notified.
Please acknowledge acceptance of the following:

Important Information

Personal Data
The insurer for policies underwriting this scheme is AXA Insurance UK plc (AXA). The scheme is administered on their behalf by Graybrook Insurance Brokers Limited.

To arrange and administer your policy AXA and Graybrook Insurance Brokers Limited will hold and use information supplied by you, in accordance with U.K. Data Protection Laws and General Data Protection Regulation (GDPR). Full information and your rights about the personal data we collect and process can be found in our Privacy Notice which is available on request and online at www.graybrook.co.uk. A copy of the Privacy Notice will also be included in your quotation/renewal pack.
Unless you select one of these options we will not be able to send information on any of our other insurance policies or services.
We will not sell or pass your information to other organisations for marketing purposes.

CUE - Insurers pass information to the Claims and Underwriting Exchange register, run by Insurance Database Services Limited (IDS Ltd). The aim is to help us to check information provided and also to prevent fraudulent claims. When we deal with your request for insurance, we may search the register. When you tell us about an incident which may or may not give rise to a claim, we will pass information relating to it to the register. You can ask for more information about this.

IPT - Insurance Premium Tax
The Finance Act 1994 requires us to levy Insurance Premium Tax at the prevailing rate on insurance premiums. For further information, please ask us.

LAW APPLICABLE
The parties to the policy have the right to choose the law applicable to the Policy. Unless the parties agree otherwise English Law shall apply

This Scheme is administered by:
Graybrook Insurance Brokers Limited, 8 Chandlers Way, South Woodham Ferrers, Essex, CM3 5TB
Web: www.graybrook.co.uk - Email: enquiry@graybrook.co.uk - Tel: 01245321185 - Fax: 01245 322240
Graybrook Insurance Brokers Limited is Authorised and regulated by the Financial Conduct Authority. Registered No. 595238

This scheme is underwritten by:
AXA Insurance UK plc
AXA Insurance UK plc is authorised by the Prudential Regulation Authority and regulated by the
Financial Conduct Authority and the Prudential Regulation Authority.