Dental 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
Name of company*
Company Number*
Trading Name
Length of time trading (years)*
Previous corporate/business names and reason for change (if applicable)
Primary practice address*
Additional practice address (if applicable)
Company website*

Primary contact details

Please enter your primary company details below
Name*

First NameLast Name
Job title*
Telephone Number*

Area CodePhone Number
Email address*
example@example.com
Primary Correspondence address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Profile
1. Describe broadly the type of services currently offered by the company and any changes expected in the next year (e.g. essential services under the General Dental Services contract). *
2. Please list the dental services delivered:*
Dental service: start date*

DayMonthYear
Date
Would you like to add additional dental services delivered?*

YesNo
Dental service
Start date

DayMonthYear
Date
Dental service
Start date

DayMonthYear
Date
Dental service
Start date

DayMonthYear
Date
4. Gross income (you may be required to provide a copy of your accounts): Last financial year (actual £)*
Current financial year (estimate £)*
Next financial year (estimate £)*
5. Previous Professional indemnity for this company
Indemnity provider
Indemnity amount
Indemnity renewal date

DayMonthYear
Date

Dental and allied professional staff details

Please tell us how many dentists, dental nurses, dental hygienists/therapists are working in or for the company as dental practitioners and provide the requested additional information.
In this section you will be asked to provide the following information for each
member of your dental staff:
- Name
- Role
- Registration number
- Hours per week worked
- Indemnity provider
6. Total dental and allied professional staff*
If you have more than 5 dental staff, please enter 0, and download the template to provide details on dental and allied professional staff.
Click here to download template
Once completed, please upload template with details of dental staff here:

Cancelof
Dental and allied professional staff: 1*
Name:
Role:
Employment status: 
No of hours worked per week:
Indemnity provider:
GDC Number:
Dental and allied professional staff: 2*
Name:
Role:
Employment status: 
No of hours worked per week:
Indemnity provider:
GDC Number:
Dental and allied professional staff: 3*
Name:
Role:
Employment status: 
No of hours worked per week:
Indemnity provider:
GDC Number:

Dental and allied professional staff: 4*
Name:
Role:
Employment status: 
No of hours worked per week:
Indemnity provider:
GDC Number:

Dental and allied professional staff: 5*
Name:
Role:
Employment status: 
No of hours worked per week:
Indemnity provider:
GDC Number:

Professional services
14. Does the company provide any of the following services?

Online advice/prescribing or e-consultationsGeneral anaesthesia or intravenous sedationAesthetic (cosmetic) dentistry
Please list aesthetic (cosmetic) medicine/dentistry*
Online advice/prescribing or e-consultations: Name and grade of practitioner/s *
Online advice/prescribing or e-consultations: volumes per month (est.)*
General anaesthesia or intravenous sedation: Name and grade of practitioner/s *
General anaesthesia or intravenous sedation : volumes per month (est.)*
Aesthetic (cosmetic) medicine/dentistry: Name and grade of practitioner/s*
Aesthetic (cosmetic) medicine/dentistry: volumes per month (est.)

Patients
15. Please indicate the number of patients listed with the company or anticipated number of patients that will be seen per year*
16. Please note below who the service is for and indicate the relative percentage of all work undertaken. NHS patients*
Private patients*
17. Do you have in place formal arrangements for:
Follow-up where necessary?*

YesNo
Communicating with the patient’s registered dentist for each assessment or treatment episode?*

YesNo

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.*

YesNo
30a. As someone who has had a criminal conviction I consent to my information being processed for this purpose*

I have consent from the individual(s)
30b. Please provide full details*
31. Are you aware of incidents that may lead to a claim involving any of the persons named in your application or the company?*

YesNo
31a. Please provide full details*
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?*

YesNo
32a. Please provide full details*

Indemnity required
33. Please indicate the maximum level of indemnity you expect to receive: (First amount is per claim; second is annual aggregate)*

£1 million / £1 million£2 million / £2 million£2 million / £4 million£3 million / £3 million£5 million / £5 million£5 million / £10 millionOther
Other - please specify:
34. When would you like your corporate dental membership to start?*

DayMonthYear
Date
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)*

YesNo
35a. Please specify what date*

MonthDayYear
Date

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
44. As a not for profit, mutual membership organisation we have to send you statutory communications. If you would prefer to receive statutory communications in paper please tick below

We want a PAPER copy
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

I do not want to receive emails from MDU with guidance and adviceI do not want to receive emails from the MDU about member services and benefits (including those we offer with third parties).
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.
Signature - authorised director (company) or designated member (limited liability partnership) *

Powered by Jotform SignClear
Name of submitted form*
Should be Empty:

Corporate application form

Primary contact details

Business Profile

5. Previous Professional indemnity for this company

Dental and allied professional staff details

Company Procedures

Locum/temporary doctors and dentists

Non-dental staff

Non-dental staff

Professional services

Patients

Quality control/risk management

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

19. Independent risk assessment, registration and review

20. Dental Equipment

Claims/complaints history

Claims/complaints history

Indemnity required

Declaration and agreement

MDU emails