MMT - Individual

Instructions
1. This form is intended for individual medical practitioners.
2. You must answer all the questions in this form. If a question is not applicable, state "N/A".
3. Please upload your IC / Passport (foreigner) and APC / equivalent at the end of this form.
4. You are encouraged to preview your submission at the end of this form before submitting your application.
5. If you have any questions concerning this form, please do not hesitate to contact us at med-indemnity@biomarking.com or call us at +6011-25445573

Quotation

Please choose the options below to quickly determine your rates.
Primary Nature of Service*
Please click HERE
Coverage Start Date*

DayMonthYear
Coverage End Date*

DayMonthYear
Limit of Liability (GP)*
Limit of Liability (GP2)*
Limit of Liability (GPL)*
Limit of Liability (GPL2)*
Limit of Liability (GPR)*
Limit of Liability (GP O&G)*
Limit of Liability (GP O&G2)*
Limit of Liability (GP Cos)*
Limit of Liability (GP Cos2)*
Limit of Liability (PAEDS)*
Limit of Liability (PAEDS2)*
Limit of Liability (GMed)*
Limit of Liability (GMed2)*
Limit of Liability (FMed)*
Limit of Liability (FMed2)*
Limit of Liability (IMed)*
Limit of Liability (IMed2)*
Limit of Liability (SB)*
Limit of Liability (SB2)*
Limit of Liability (Chiro)*
Limit of Liability (Chiro2)*
Limit of Liability (Chiro)*
Limit of Liability (GD)*
Limit of Liability (GD2)*
Limit of Liability (Ort)*
Limit of Liability (Ort2)*
Limit of Liability (Perio)*
Limit of Liability (Perio2)*
Limit of Liability (Dent)*
Limit of Liability (Dent2)*
Limit of Liability (Endo)*
Limit of Liability (Endo2)*
Limit of Liability (Prostho)*
Limit of Liability (Prostho2)*
Limit of Liability (Gastro)*
Limit of Liability (Gastro2)*
Limit of Liability (Radio)*
Limit of Liability (Radio2)*
Rate - GP
Rate - GP2
Rate - GPL
Rate - GPL2
Rate - GPR
Rate - GPR2
Rate - GP O&G
Rate - GP O&G2
Rate - GP Cos
Rate - GP Cos2
Rate - PAEDS
Rate - PAEDS2
Rate - GMed
Rate - GMed2
Rate - FMed
Rate - FMed2
Rate - IMed
Rate - IMed2
Rate - SB
Rate - SB2
Rate - Chiro
Rate - Chiro2
Rate - GD
Rate - GD2
Rate - Ort
Rate - Ort2
Rate - Perio
Rate - Perio2
Rate - Dent
Rate - Dent2
Rate - Endo
Rate - Endo2
Rate - Prostho
Rate - Prostho2
Rate - Gastro
Rate - Gastro2
Rate - Radio
Rate - Radio2
Your Final Rate (RM)
Your Final Rate (Billplz)

Quick Claim Experience Check
Have any claims ever been made, or lawsuits been brought against you?*

YesNo
Please click HERE

Application Form
Full Name*
NRIC / Passport*
without dash (-)
Date of Birth

DayMonthYear
Gender*

MaleFemale
Correspondence Address*
Primary Practice Location*
Name of Clinic/Hospital
Contact Phone Number*
Please input your valid mobile number
Email*
example@example.com

Insurance History
Do you currently have any medical malpractice individual practitioner’s Takaful/Insurance?*

YesNo
If YES, please upload your certificate.

Previous Professional Medical Indemnity certificate
Cancelof
Or provide the details of coverage
Name of insurer
Period of coverage
Coverage limit

Claim Experience
Have you ever had any application for medical malpractice individual practitioners Takaful/Insurance , or had any medical malpractice individual practitioners Takaful/Insurance coverage refused, rescinded or cancelled?*

YesNo
Are you aware of any errors, omissions, offences, circumstances or allegations which might result in a claim being made against you?*

YesNo
Have you ever been the subject of disciplinary action or investigation by any authority or regulator or professional body?*

YesNo
Have you ever been the subject of a criminal investigation or had criminal charges brought against you? For the purposes of this question, please disregard traffic or minor motor vehicle licensing offences.*

YesNo
If you had answered Yes to any of the questions in this section, please provide full details overleaf and the status of each claim, lawsuits, allegation or matter, including
- the date of the claim, suit or allegation
- the date you notified your previous Takaful Operators
- the name of the claimant(s) and the services rendered
- the allegations made against you
- the amount claimed by the claimant(s)
- whether the status is outstanding or finalised
- the amounts paid for claims and defence costs to date
File Upload

Cancelof

Details of E-Payment

Please fill your bank details to facilitate e-payment for any amount due and payable to YOU
Bank Account Number
Account Holder Name
Bank Name

Please upload your latest APC*

Cancelof
Please upload your copy of Identity Card/ Passport (non-local)*

Cancelof

Signature*

Clear
Date

DayMonthYear
Date
Campaign Voucher Code
If you have a voucher code, please key-in here
Gross Rate
6%
Stamp Duty
Phone number (Billplz)
Should be Empty: