MMT - Establishment

Instructions
1. This form is intended for health facilities. These include hospitals, clinics, outpatient care centres and specialised care.
2. This proposal must be completed, signed and dated by a Principal, Partner or Director.
3. You must answer all the questions in this form. If a question is not applicable, state "N/A".
4. If you are a new business, use the projected figures from your business plan.
5. You are encouraged to preview your submission at the end of this form before submitting your application.
6. 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

Has your company's name ever been changed, or have you purchased or merged with any other practice or business?

YesNo
If YES, please attach details.

ie : SSM previous company's name
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Please indicate the number of personnel applicable below

	Part Time	Full Time
Principals, partners or director
Doctors (including locum doctors)
Surgeons
Interns
Registered Nurse
Enrolled Nurses
Pharmacist
Laboratory Technicians
Dentist
X-ray Technicians
Physiotherapists
Midwives
Healthcare assistance / health workers
Other registered Professionals
Other skilled & technical employees
Non-technical administrative staff
Other staff (please specify)
Total

What are qualifications and experience of your Principals, Partners, Directors (PPD)?

	Name of Principals/Partners/Directors	Qualifications	Year Qualified	Current Practice as PPD (years)	Previous Practice as PPD (years)
1
2
3
4
5

If there is only a sole Principal, what arrangements do you have in place to ensure business continuity when that Principal is travelling, on leave, ill or away from the office?
Which professional societies & associations are you, your Principals, Partners or Directors member of? (ie. MMA, MDC)

Details of Business
Is your practice entity duly licensed to practice at the address(es) specified?*

YesNo
Do you ensure that all doctors providing medical services for or using the facilities of your firm are members of a Medical Defense Union or Medical Protection Society or otherwise carry their own medical malpractice takaful/insurance covers?*

YesNo
If NO, are you requesting coverage for these doctors as part of your application?

YesNo
Are you ISO 9001 certified?*

YesNo
If YES, when was this achieved and for which activities?

	Number of patients
Outpatients
Inpatients

Do you own or operate a heliport or helipad?

YesNo
Number of annual landings
Where are the helicopters/helipads located?

LawnRoofCarparkOther
Is the helicopter landing pad approved by the governing aviation authority?
Is the medical team comprised of certified and experienced retrieval medicine physicians and registered nurses with critical care and emergency nursing experience?

YesNo
If NO, please provide supporting details

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What percentage of your activities are represented by each of the following of professional healthcare services :

	Percentage (%)
Audiology
Aged Care/Assisted Living
Cardiology
Oncology
Ophthalmology including Lasik and Laser
Pediatrics
Communicable Disease/ Tubercular
Dentistry
Dermatology
Drug/alcohol dependency
Ear/Nose/Throat
Elective Termination
Gastroenterology
General Practice/General Medicine
Gynecological
In vitro fertilisation (IVF)
Obstetrics/maternity
Pathology
Physiotherapy
Plastic surgery (elective cosmetic)
Plastic surgery (reconstructive)
Podiatry
Psychiatric
Radiography/medical imaging
Rehabilitation
Surgical
Traditional machine
Other Please specify

Do you engage in any other professional healthcare services or business activities other than what is described in this section?*

YesNo
If YES, please attach details of the type of work and the fee income from these other activities.

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Are you or any of your Principals, Partners or Directors connected or associated with any other practice or business?

YesNo

What is your total turnover / fee income of the following financial year

Please indicate your patient demographic

Insurance History
Do you currently hold medical malpractice takaful / medical indemnity insurance?*

YesNo
If YES, please upload your previous certificate / policy;
File Upload

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Or write in the details of coverage :
Period of Coverage
ie : 01/05/2022 - 30/4/2023
Takaful / Insurance Operator
Limit of Liability
ie: RM 5,000,000
Excess
If applicable
Retroactive Date

DayMonthYear

Have you ever had any application for medical malpractice takaful / insurance refused, or had any medical malpractice takaful / insurance coverage rescinded or cancelled?*

YesNo
If YES, please upload details, noting the Section number.

Cancelof

Claim Experience
Have any claims ever been made, or lawsuits been brought against you, your predecessors in business, or any current or former Principals, Partners, Directors, employees, or any other person or entity applying to be covered under this proposed contract of takaful?*

YesNo
Are any of the Principals, Partners, Directors or employees aware, after inquiry, and as of the date of signing this application, of any errors, omissions, offences, circumstances or allegations which might result in a claim being made against you or any person or entity applying to be covered under this proposed contract of takaful?*

YesNo
Have you, your predecessors in business, or any current or former Principals, Partners, Directors, or employees ever been the subject of disciplinary action or investigation by any authority or regulator or professional body?*

YesNo
If you had answered YES to any of the questions in this section, please provide full details 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 operator
- the name of the claimant(s) and the establishment(s)
- 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

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Additional Information

In order to facilitate the e-payment for any amount due and payable to you i.e. payout on claim, cancellation or surplus distribution, please complete this section. (optional)
Bank Account number
Account Holder Name
Bank Name