• Medical Malpractice & Public Liability Insurance for Move It or Lose It Trainers

    Fields marked with * are required

  • You should refer to the policy summary & wording for full details of the insurance cover provided.
    If you need assistance in completing any of the sections, please contact us on 01245 321185

  • Information About You

  • Are you a Member of any Association?*
  • Is it a Full or Student membership?
  • Date the Business was established*
     - -

  • Activities you wish to Insure
    You must accurately describe and list below all activities for which you are qualified to undertake and for which insurance is required.  You must also demonstrate you have successfully completed an appropriate and recognised course if requested for each activity listed and insert below the percentage of your total annual income against each activity declared.

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  • Do you undertake injection therapy?*

  • If Yes, please complete the boxes below:- 

    Important Note: No cover is available for Injection of Lipogems and Ultrasound Guided Stem Cell Injections or Spinal Injections

  • Do you undertake Acupuncture or Dry Needling treatments?*

  • If Yes, please complete the boxes below:-

    Important Note: No cover is available for acupuncture related to fertility treatment when undertaken by Physiotherapists

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  • *When Doctors, Nurses, Midwives or Surgeons are declared, full details of their activities must be submitted before cover can be agreed.

     

    It is a condition of this insurance that all self-employed practitioners and sub-contractors engaged by your business must maintain Medical & Public Liability Insurance in their own name to the same limit of indemnity as you select for your own business and be maintained during the period of their engagement and for at least 3 years after termination of their services.
     
    All therapists, whether employed or self-employed must be suitably qualified and maintain registration with HCPC or other statutory regulator where required.

  • Limits of Indemnity

  • The standard limit of indemnity is £5,000,000, if a higher limit is required please contact us.

  • Employers' Liability

  • Do you require Employers Liability Insurance*

  • This is an option you should consider if you engage employees, self-employed persons, volunteers (including students on work experience) for whom you may be liable for any work-related illnesses or injuries.

  • If Employers Liability Insurance selected, you must provide the Employers PAYE reference number. This is usually a unique reference comprising letters and numbers (e.g. 012/AB34567).

  • First Aid and Related Activities

  • Do you attend outside events which may include ancillary First Aid?*
  • Do you attend to offer First Aid ONLY?*

  • If you have answered Yes to either the above, please state:

  • Do you offer Wound Management*
  • Do you offer Suturing*
  • Do you offer Sports Trauma Management*

  • If yes, please note that the policy is only intended to cover all the above activities as ‘First Response’ only.

  • Disclosure of Fair Presentation

  • Your Duty of Disclosure

    IMPORTANT NOTICE CONCERNING YOUR DUTY TO MAKE A FAIR PRESENTATION OF THE RISK

    Before your insurance policy takes effect, you have a duty to make a fair presentation of the risks to be insured under your insurance policy. A fair presentation of the risk is one which disclose to the Insurer every material cirumstance which you know of or ought to know of; or gives the Insurer sufficient information to put the Insurer on notice that they will need to make further enquiries for the purpose of revealing those material circumstances, which makes that disclosure referred to above in a manner which is reasonably clear and accessible to the Insurer; and in which every material representation as to a matter of fact is substantially correct, and every material representation as to a matter of expectation or belief is made in good faith.

    A material circumstance is one that would influence the Insurer's decision as to whether or not to agree to insure you and, if so, the terms of that insurance. If you are in any doubt as to whether a circumstance is material, you should disclose it to the Insurer.

     

    Please answer the following:

  • a) Have there been any claims made against you or any Director, Principal, Employee or any other person engaged by you or any previous company in respect of any of the covers now proposed and are you aware after enquiry of any circumstances that could give rise to a claim?*
  • a) Have there been any claims made against you or any Director, Principal, Employee or any other person engaged by you or any previous company in respect of any of the covers now proposed and are you aware after enquiry of any circumstances that could give rise to a claim?*
  • b) Do you or are you likely to undertake work in Australia or North America including Canada?*
  • c) Do you or are you likely to undertake any work elsewhere outside of the U.K. for more than 90 days a year? Please be aware this policy contains significant restrictions relating to activities undertaken outside of the United Kingdom.*
  • d) Do you provide treatment to any Professional Footballer? Please be aware this policy contains significant exclusions relating to the treatment of Professional Footballers*
  • e) Have you or any Partner, Director, Employee or other persons engaged by you ever been the subject of a fitness to practice or disciplinary hearings or criminal prosecutions (excluding motoring convictions)?*
  • f) Have you or any Partner, Director or Employee been refused insurance or had special terms imposed?*
  • g) Have you or any Partner, Director, Employee or any other person engaged by you either been declared bankrupt, disqualified from holding office or had a County Court Judgement awarded against them?*
  • h) Do you check on appointment and annually that all self-employed persons or sub-contractors maintain their own Medical Malpractice & Public Liability Insurance up to the same limit as your own for the duration of their engagement and up to 3 years following termination of their services?*
  • i) Do you check on appointment at least annually that all Healthcare Professionals are registered where required with the HCPC or other relevant statutory regulator?*
  • j) Have you previously held Medical & Professional Liability Insurance?*

  • If Yes, please provide the following details:

  • Retroactive Date
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  • Expiry Date
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  • When do you wish the policy to start?
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  • Important Notes:

    • This policy is issued on an OCCURRENCE basis which only covers claims arising from activities undertaken during the currency of the policy.
    • Cover will not commence until this application has been approved and a Quotation issued and accepted.
    • Policies will run for 12 months from the agreed start date.
    • No activities undertaken prior to commencement of the policy is insured unless agreed and noted in the Retroactive Endorsement. (Retroactive cover may be available subject to evidence of previous and continuous insurance)

  • DECLARATION AND UNDERTAKING

    I declare that every statement and particular contained within this proposal form: which is a statement of fact, is substantially correct, and which is matter of expectation or belief, is made in good faith.

    If any such facts, expectations and/or beliefs materially change before the insurance policy takes effect I undertake to provide details of all such changes to the Insurer in order to comply with my obligation to provide a fair presentation of the risk to be insured under the Insurance Policy. I consent to the processing of any sensitive personal data in order to administer and underwrite this policy. I agree to accept the insurer’s standard form of policy and endorsements for this insurance. I confirm that all persons carrying out activities in accordance with the Business or Occupation as defined above are suitably qualified to do.

     

  • Date*
     - -

  • Important Information

  • Personal Data
     
    The insurer for policies underwriting this scheme is RSA Insurance Group Ltd. (RSA). The scheme is administered on their behalf by James Hallam ProMed.


    To arrange and administer your policy RSA and James Hallam Pro Med will hold and use information supplied by you, in accordance with U.K. Data Protection Laws and General Data Protection Regulation (GDPR). Full information and your rights about the personal data we collect and process can be found in our Privacy Notice which is available on request and online at www.jameshallam.co.uk/promed  A copy of the Privacy Notice will also be included in your quotation/renewal pack.

  • James Hallam ProMed would also like to send you details from time to time of their other related insurance products/services which may be of interest and benefit to you. 

    Please select if you with to receive such details by:

  • Marketing Opt In

  • Unless you select one of these options we will not be able to send information on any of our other insurance policies or services.

    We will not sell or pass your information to other organisations for marketing purposes.

     

    A copy of the proposal should be retained by you for your own records.

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