Corporate application form

  • Corporate application form

  • Apply for your corporate indemnity solution by completing this form.

    Corporate membership benefits are provided on a “claims made” basis which means requests for assistance, arising from incidents when you were a corporate member, can only be made during a membership year and not after you have left corporate membership.

    Please enter your company details below (the entity to be indemnified - company or LLP).

    NOTE: Throughout this form, please do not use the back button in your browser as you may lose the details you have entered on your form. If you need to return to a previous page, please use the button at the bottom of this page.

    As an organisation, we understand that data must be handled securely. For more information about how we collect, store and use data please see our privacy policy at themdu.com/privacy

  • Primary contact details

    Please enter your primary company details below
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  • Business Profile

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  • Would you like to add additional clinical services?*
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  • 5. Previous Professional indemnity for this company

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  • Clinical and allied professional staff details

    Please tell us how many doctors, dentists, nurses, dental hygienists/therapists, paramedics, clinical pharmacists, practice/staff nurses, nurse practitioners, advanced nurse practitioners, nurse consultants/clinicians, and/or nurses in extended roles working in or for the company as clinicians and provide the requested additional information.

  • In this section you will be asked to provide the following information for each
    member of your clinical staff:

    • Name
    • Role
    • Registration number
    • Hours per week worked
    • Indemnity provider

  • Click here to download template

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  • Company Procedures

  • 7. Does the company have in place a formal procedure for determining that all doctors/dentists, whether employees, or contractors, temporary or permanent:

  • have and maintain their own personal indemnity?*
  • are registered with the GMC/GDC?*
  • are appropriately qualified to undertake the work required of them?*

  • 8. Does the company have in place a formal procedure for determining that all
    of its non-doctor and non-dentist clinical staff, including nurses, pharmacists
    and paramedics:

  • are registered by the appropriate registration body?*
  • are appropriately qualified to undertake the work required of them?*

  • Locum/temporary doctors and dentists

  • Do you provide in every case: an induction programme?*
  • an induction handbook?*

  • Non-clinical staff

  • Do staff have their own clinical indemnity arrangement?*
  • Does each staff member have full registration with the HPC or other statutory regulatory body?*
  • Do staff have their own clinical indemnity arrangements?*
  • Does each staff member have full registration with the HPC or other statutory regulatory body?*
  • Do staff have their own clinical indemnity arrangements?*
  • Does each staff member have full registration with the HPC or other statutory regulatory body?*
  • Do staff have their own clinical indemnity arrangements?*
  • Does each staff member have full registration with the HPC or other statutory regulatory body?*
  • Do staff have their own clinical indemnity arrangements?*
  • Does each staff member have full registration with the HPC or other statutory regulatory body?*

  • Non-clinical staff

  • For agency/temporary staff do you provide in every case: an induction programme?*
  • an induction handbook?*

  • 12. Does the company have formal procedures for ensuring that clinical staff, other than medical/dental practitioners, are provided with:

  • training?*
  • supervision as appropriate?*
  • continuing education (except temporary staff)?*
  • appraisal/assessment (except temporary staff)?*
  • a confidentiality clause included in their contract/terms of service?*

  • 13. Does the company have formal procedures for ensuring that non-clinical staff are provided with:

  • training?*
  • supervision as appropriate?*
  • a confidentiality clause included in their contract/terms of service?*
  • appraisal/assessment (except temporary staff)?*

  • Professional services

  • 14. Does the company provide any of the following services?*

  • Patients

  • 17. Do you have in place formal arrangements for:

  • Follow-up where necessary?*
  • Communicating with the patient’s registered GP for each assessment or treatment episode?*

  • Quality control/risk management

  • 18. Does the company adopt the following quality controls and risk management procedures?

  • Are patients provided with written material routinely as part of the consent procedure?*
  • Are patients consented by the practitioner who will be undertaking the procedure in every case assessment or treatment episode?*
  • Are there protocols in place for the management of standard, frequently encountered conditions?*
  • Is there a system of ongoing audit to ensure compliance with protocols?*
  • Is there a formal complaints procedure?*
  • Is there a system for the reporting and investigation of adverse/significant events?*
  • Is there a Health and Safety policy?*
  • Is there periodical Health and Safety training for staff (e.g. manual handling)?*
  • Is there a protocol to ensure that good quality, contemporaneous medical and dental records are made after all clinical contacts with patients (including telephone contacts)?*

  • 19. Independent risk assessment, registration and review

  • Has the company had a risk assessment carried out by an independent organisation within the last three years?*
  • Has the company been subject to a review by a CCG, the Care Quality Commission, or other body?*
  • Are you required to register with the Care Quality Commission (England) or equivalent in Wales, Scotland and Northern Ireland?*
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  • 20. Clinical Equipment

  • Are there procedures in place for checking and maintaining clinical equipment or devices owned by the company?*
  • Are leased devices or clinical equipment regularly checked and maintained by the supplier?*

  • Claims/complaints history

  • 21. Has the company or any employee or contractor of the company, been the subject of a complaint related to the provision of clinical services?*
  • 22. Has the company or any employee or contractor of the company had a claim within the past 10 years?*
  • 23. Have any persons named earlier been charged with, or convicted of, a criminal offence, or received a formal Police Caution? (We need the consent of the person who has had the criminal conviction to process information about spent criminal convictions and police charges to assess the accuracy of events notifiable to regulators of fitness to practise.)*
  • 24. Are you aware of circumstances that could lead to an investigation or suspension, for any employee/contractor or relating to the company generally?*
  • 25. Are you aware of any circumstances that could lead to the company being prevented from carrying on its business?*
  • 26. Are you aware of incidents that may lead to a claim involving any of the persons named earlier or the company?*
  • 27. Has the company, or any of the persons named earlier, ever had professional indemnity insurance or medical/ dental defence organisation membership declined, cancelled, not renewed or special terms imposed?*
  • 28. Are there or have there been any insolvency proceedings involving the company including winding up proceedings, receivership or administration?*
  • 29. Are there any other facts or circumstances that may be relevant to consideration of the application?*

  • Claims/complaints history

    For individuals identified earlier in your application, after enquiry, please answer the following questions to the best of your knowledge.
  • 30. Have any of the persons named in your application been charged with, or convicted of, a criminal offence, or received a formal Police Caution? Include any motoring offence even if you were fined but not imprisoned but exclude fixed penalty notices for speeding offences or parking tickets. You should not disclose any cautions or convictions which are ‘protected’ under the 2013 amendment to the Rehabilitation of Offenders Act 1974 Exceptions Order 1975.*
  • 31. Are you aware of incidents that may lead to a claim involving any of the persons named in your application or the company?*
  • 32.Has the company, or any of the persons named in your application, ever had professional indemnity insurance or medical/ dental defence organisation membership declined, cancelled, not renewed or special terms imposed?*

  • Indemnity required

  • 33. Please indicate the maximum level of indemnity you expect to receive: (First amount is per claim; second is annual aggregate)*
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  • 35. Are benefits of membership needed for incidents occurring prior to the membership start date? (Note: indemnity will not be available for incidents recorded or which should have been recorded earlier in this form)*
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  • Declaration and agreement

  • APPLICATION FOR THE CORPORATE INDEMNITY SOLUTION INCLUDING CORPORATE MEMBERSHIP OF THE MEDICAL DEFENCE UNION LIMITED

    We hereby apply for membership of The Medical Defence Union Limited (the MDU), in accordance with its Memorandum and Articles of Association.

    We understand and acknowledge that

    • MDU Services Limited (MDUSL) is the service company for the MDU and any notices or information which I am required to give to the MDU should be sent to MDUSL
    • benefits of membership of the MDU are discretionary and are subject to its Memorandum and Articles of Association
    • with the exception of Good Samaritan acts, the benefits of membership do not extend to any practice undertaken in the USA or Canada or any litigation which may arise in these countries or in the territories and principal island groups under their sovereignty. Restrictions also apply for other countries
    • we must notify MDUSL in writing of any change in address, or any other circumstance which may be relevant to membership
    • we will inform our employees that their personal data will be shared with the MDU for the purposes of administering our corporate membership and advise them of the MDU’s privacy policy
    • a condition of membership of the MDU is that any misrepresentation or misstatement in, or omission of, any information which is likely to influence the acceptance or assessment of this application, whether intentional or not, is cause for immediate rejection of this application or termination of membership and that in such circumstances all benefits of membership of the MDU may be withdrawn or denied
      benefits of membership will not commence until our application for MDU membership has been accepted
    • if we are reviewed by, or any action is taken against us, by a CCG or the Care Quality Commission, or we suffer loss of registration or any other action by a regulatory, government or legal authority, this must be notified to MDUSL immediately as membership may be affected. We declare that to the best of our knowledge and belief the information provided in connection with this application is true and we have not withheld any material facts.
    • How your information will be used
      The Data Controller for your Data is the Medical Defence Union Limited. The MDU privacy policy sets out, in detail, what personal information it holds about you and how it is used.
    • The MDU will use your personal information for the purposes outlined in their privacy policy which include: to administer your membership and provide your benefits and services of membership including providing advice and to administer legal claims. Find out more at themdu.com/privacy
    • The MDU may share your personal information with third parties to assist with the provision of these services and only where the law permits.

    Statutory communications

    We agree to:

    • having access to the MDU’s annual accounts, directors’ report and auditor’s report, and any other documents or information sent or supplied by the MDU, on the MDU website at themdu.com
    • notice of general meetings of the MDU being given to us by access to the MDU website, together with details of any proxy appointment deadlines
    • being notified by email, with a link provided to the relevant information, of the publication or availability of notice of general meetings, or any other documents or information sent or supplied by the MDU, on the MDU website
    • notify MDUSL of our email address, which may be used for sending email for the above purposes. Any email address given by us elsewhere on this form is the relevant email address for this purpose, until we notify any change. We understand that if the MDU does not have our email address, we will receive notification by post instead of by email
    • notify MDUSL of changes in our email address

    Further information on email communication and statutory information, including any system requirements, is available at themdu.com/agm

  • MDU emails

    Please indicate below if you do not want to receive our emails. You can change your communication preferences at any time on your website
  • To help you make the most of your membership, we will send you emails

  • STATEMENT

    We have read, understood and advised our employees that their personal data will be shared with the MDU for the purposes of administering membership in accordance with the privacy policy. We confirm that the information provided within this form is complete and an accurate representation of our practice. We authorise and request our current and any former medical/dental defence organisation, insurance company or indemnity provider to release to MDU Services Limited information regarding our membership or insurance or indemnity contract, complaints of a medico-/dentolegal nature, claims or actions for damages or compensation, past or present, during our period of membership and/or indemnity, whether or not there has been a final resolution, and we understand that if we do not provide our authority, this will be considered when processing our application and is likely to adversely affect the outcome of our application.

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