01245 321185

Medical Malpractice & Public Liability Insurance for HPA Members Application Form

Date: 27/05/2020

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 Allied World Assurance Company (Europe) dac. The scheme is administered on their behalf by Graybrook Hallam.

To arrange and administer your policy Allied World Assurance Company (Europe) dac and Graybrook Hallam 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.

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