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What It Covers | Covering Clause
▪ Limits include Defence Costs & Aggravated Damages
▪ Unlimited Retroactive Cover excluding known claims & circumstances
▪ Unlimited Run-Off Cover, providing protection into retirement
▪ Defence costs for Regulatory Investigation, Inquiries & Disciplinary Proceedings
▪ Public Relations & Crisis Management cost & expenses
▪ Loss of documents e.g., computer records & electronic data (sub-limit applies)
▪ Breach of confidentiality
▪ Defamation
▪ Intellectual property
▪ Misleading or deceptive conduct
▪ Retroactive Date
▪ Compensation for court attendance
▪ Locums tenens
▪ Spouses, domestic partners, estates, heirs, legal representatives or assigns
▪ Unlimited Run Off cover

Please refer to the policy contract for the full details of benefits, terms and exclusions that are applicable.

The information provided here is a brief summary for quick and easy reference.

The exact terms and conditions that apply are stated in the policy contract.

Proposal Form:
Professional Indemnity for Individual General Dentists & General Practitioners

Policy Wording:
Professional Indemnity for Individual General Dentists & General Practitioners

Underwritten By Pacific Insurance

E-APPLICATION

Professional Indemnity For General Dentist (GD) & General Practitioner (GP) *GP Includes care of Patient & Pregnancy Management under 24 weeks gestation, excluding deliveries. | GP with Obstetrics For GPs who also provide care of Patient and Management of Pregnancy beyond 24 weeks gestation excluding deliveries. GP is NOT registered on any Specialist Register.

Name of Proposer: *

Name of Hospital/Clinic Place of Practice In Full *

Address *

City *

State/Province *

ZIP / Postal Code *

Country

NRIC Number: (For Malaysian) | Passport Number: (For non-Malaysian) *

No file chosen

NRIC Front

NRIC Number: (For Malaysian) | Passport Number: (For non-Malaysian) *

No file chosen

NRIC Back

Nationality (if non-Malaysian): *

Date of Birth: *

Contact Mobile Number *

Mailing address In Full *

City *

State/Province *

ZIP / Postal Code *

Country

Email Address *

Employment Status *GovernmentPrivate Practice

Malaysia Medical Council (MMC) Full Registration Number *

Professional Associations of which you are members: *

Qualification details: Institution *

Qualification details: Qualification *

Qualification details: Date Obtained *

Annual Practicing Certificate (APC) *

No file chosen

Please upload APC here.

Q1. Do you currently have OR have you ever had any medical professional indemnity insurance? If yes: *

If Yes, please provide details in here.

Q2. Have you ever been refused medical professional indemnity insurance before? *

If yes, please provide reasons.

Q3. CLAIM: Are you aware of any claim against you OR have you ever been involved, directly or indirectly in a claim, or suit arising from your practice? *

If YES, please give details.

Q4. CIRCUMSTANCE: Are you aware of any circumstance or incident that may give rise to a claim against you? *

If yes, please give details.

Q5. REGULATORY/DISCIPLINARY PROCEEDINGS: Were you ever subject to OR are you currently aware of any potential OR currently named/involved in any such proceedings? *

If yes, please give details.

Declaration and Signature *The undersigned, having made all necessary enquiries, declare that to the best of my knowledge and belief the statements in this proposal form and all attachments and schedules are true and complete; and immediate notice will be given to the Insurer should any of the above information alter between the date of this Proposal and the date of inception of the Policy.Signing of this Proposal does not bind the Applicant or the Insurer to complete the insurance contract, but it is agreed that this Proposal shall be the basis of the contract should a Policy be issued, and it will be attached to and become part of the Policy. All written statements and materials furnished to the Insurer in conjunction with this Proposal are incorporated by reference into this Proposal and made a part hereof.The Insurer and/or their representative are authorised to make any investigation and inquiry in connection with this application as is reasonable and necessary. Nothing contained in this Proposal shall constitute notification of a claim or potential claim. I/We also authorise the Insurer and/or its authorised representatives to disclose from time-to-time such information arising from any claim under the insurance cover for the sole purpose of the management of this DR.cover facility and its risk management objectives.I/We have fully read and understood the terms and conditions set out in the Insurer’s Privacy Notice https://www.pacificinsurance.com.my/pdpa/ and consent to collection, use, disclosure, transfer, and processing of my / our Personal Information in accordance with the Personal Data Protection Act 2010. This includes personal data in the possession or under control of the Insurers, including personal data in the possession of organisations which the Insurer has engaged to collect, use, disclose or process personal data for the Insurer’s purposes.

I also declare that: *1. My medical license or my privileges at any hospital or institution have never been revoked, suspended, restricted, or placed on probation.2. I have never been investigated by any licensing board, narcotics board, or other governmental or regulatory agency nor any fee or professional relations complaints have been filed against me with medical associations, hospitals, or licensing authorities.3. I have not been indicted for, charged with, or convicted of, any act committed in violation of any law or ordinance other than traffic offenses4. No allegation or claim has even been made against me regarding sexual harassment, sexual intimacy, exploitation, or sexual assault in the conduct of my practice or otherwise.5. I have never intentionally altered or falsified patient records or knowingly made any change, correction, or addition without properly noting it as such.6. I have never been diagnosed, or a mental or treated for alcoholism, drug addiction, any chemical dependency, or a mental or chronic physical illness.7. With respect to my professional indemnity coverage, no insurance company or mutual has ever canceled, refused to renew, or restricted my coverage.8. I am registered with the Malaysian Dental Council/Malaysian Medical Council and have a valid full registration number.

Name:

Designation:

Date:

By printing your name in both the Signature and Name sections below and submitting it to us and/or our authorised representative, you are agreeing that it is the legal equivalent of your manual signature on the Form. *

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