Application for membership - state indemnified consultants and hospital doctors

  • Application for membership

    State indemnified consultants and hospital doctors

  • Please complete the following to apply for membership.

    This membership is for doctors who don't do any private clinical work. It doesn't include indemnity for clinical negligence claims. It includes indemnity for certain fee-paying non-clinical work, providing you will not earn more than €1,500 gross each year. For more details of this work, refer to the member guide.

    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. We may use your data to contact you about the application, including incomplete applications.

  • Your details

  • Date of birth*
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  • Ireland application date
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  • MDU Services Limited (MDUSL) is authorised and regulated by the Financial Conduct Authority for insurance mediation and consumer credit activities only. MDUSL is an agent for The Medical Defence Union Limited (MDU). MDU is not an insurance company. The benefits of MDU membership are all discretionary and are subject to the Memorandum and Articles of Association. MDU Services Limited, registered in England 3957086. Registered Office: One Canada Square, London E14 5GS

  • Is all your clinical work indemnified by the Clinical Indemnity Scheme (Enterprise Liability)?*

  • Unfortunately we are unable to proceed with your application, as this product is not appropriate for doctors undertaking clinical work that is not indemnified by the Clinical Indemnity Scheme (Enterprise Liability).

  • Do you undertake any work outside the Republic of Ireland (including the UK?)*

  • Please call our membership team on 1800 509 132 between 8am and 6pm, Monday to Friday to discuss your working circumstances further.

  • Do you undertake any non-clinical work that is not indemnified by the Clinical Indemnity Scheme (Enterprise Liability)?*
  • Is your gross annual income from this non-clinical work more than €1500?*

  • Unfortunately we are unable to proceed with your application, as this product is not appropriate for doctors earning over €1500 from non-clinical work that is not indemnified by the Clinical Indemnity Scheme (Enterprise Liability).

  • Is all the non-clinical work you undertake included in the list below?*

  • By non-clinical work we mean work that does not involve the care of individual patients. It may involve the examination of patients for the purposes of providing a factual report but in circumstances where you do not act as an expert. This can include the work detailed below:

    • Provision of medical reports
    • Provision of witness statements for the Garda
    • Provision of reports to the coroner
    • Safeguarding work (adults and children)
    • Assessment of testamentary capacity
    • Signing death notification forms and cremation forms (including pacemaker removal)
    • Academic, research and lecturing activities including the supervision of students and doctors in training
    • Clinical and non-clinical audit
    • Acting as an examiner for a Royal College or Faculty
    • Medical assessor for the Medical Council
    • Reports to the Mental Health Commission
  • What is your role?*

  • What is your main work address?

  • Academic Qualifications

  • Do you like to add another qualification?*
  • Would you like to add another qualification?
  • Have you ever held any professional indemnity/insurance before?*
  • Add another indemnifier?
  • Add another indemnifier?

  • MDU Services Ltd may request your authority to seek confirmation of your indemnity history at any time to validate the answers provided. Failure to provide this authority, if requested, or any identified misrepresentation made in this application could lead to termination of membership and may be taken in to account if you seek our assistance. 

  • 1) In the last 10 years, have you had any complaints or claims brought or threatened against you, irrespective of their merits or seriousness?*
  • 2) Have any concerns ever been raised about your personal or professional conduct, clinical work, educational progress or probity by an employer, academic body, HSE hospital or other HSE body or organisation, voluntary or private healthcare provider or any other body (e.g. Health Information and Quality Authority and Mental Health Commission)? **
  • 3) Have you ever been the subject of an investigation or action under a disciplinary process relating to your professional practice or personal conduct, irrespective of the merits or seriousness of the matter that led to this?*
  • 4) Have you ever been suspended or dismissed from a post or had practice privileges or admitting rights withdrawn, suspended or made subject to restrictions or conditions?*
  • 5) Have you ever been the subject of an investigation or an adverse finding by a registration or licensing body (e.g. any complaint, regardless of outcome, to the Medical Council that was considered by its Preliminary Proceedings Committee, Fitness to Practise Committee or its Council; including Immediate Suspension Orders (Section 60 Orders) and concerns raised about professional performance or health)?*
  • 6) Have you ever had any condition, suspension, undertakings or advice, admonishment or censure in writing or restrictions imposed on your registration or licence to practise, or been removed, refused or erased from registration or had a licence to practise withdrawn or refused, by a registration or licensing body?*
  • 7) Are you aware of any incidents or circumstances involving you, irrespective of their seriousness, which could lead to an investigation, complaint, claim, disciplinary action, legal dispute, suspension from practice, imposition of restrictions or conditions on your registration or licence to practise, or your removal from a professional register or of your licence to practise, by a registration body?*
  • 8) Have you ever been charged with, or convicted of, a criminal offence, or received a formal Adult Caution (including any motoring offence even if you were fined but not imprisoned but excluding fixed charge notices for speeding offences or parking tickets. You should not disclose any convictions which are 'spent' under the Criminal Justice (Spent Convictions and Certain Disclosures) Act 2016 except in any circumstance where section 6 of the Act does not apply)?*

  • We need information about spent criminal convictions and police charges to assess the accuracy of events notifiable to regulators of fitness to practise.

  • 9) Has any professional indemnity provider or insurer ever declined to indemnify or insure you, required special terms to indemnify or insure you, cancelled or refused to renew indemnity or insurance or charged you an additional premium/subscription?*
  • 10) Have you ever been bankrupt or subject to insolvency proceedings, applied for a Debt Relief Notice or entered into or proposed any voluntary arrangement with creditors such as a Debt Settlement Arrangement or Personal Insolvency Arrangement?*
  • 11) Other than information you have already notified us of in this application, have you sought any assistance from an indemnity provider or insurer in the past 10 years (other than telephone advice) or are you aware of any reason that you may need to do so?*
  • When would you like your membership to start?  (You can start your prospective membership on any date in the next three months. This does not constitute acceptance of your membership, however we will notify you if you are successful)*
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  • If your application is successful, how would you like to pay? A single annual payment of the full subscription amount will be required.  We will contact you once your application has been processed.*

  • SEPA Direct Debit Mandate

    By signing this mandate form, you authorise (A) MDU Services Limited to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from MDU Services Limited. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that you can obtain from your bank.

  • Unique Mandate Reference (UMR) – to be completed by MDU Services Limited
    OFFICE USE ONLY

  • Creditor's Name Creditor's Identifier Creditor's Address
    MDU SERVICES LTD IE67SDD993076 ONE CANADA SQUARE
         
    City Postcode Country
    LONDON E14 5GS UNITED KINGDOM

  • Please complete all the fields marked *

  • Declaration agreement

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

    I understand and acknowledge that

    • this membership is for doctors who don't do any private clinical work and it does not include indemnity for clinical negligence claims;
    • 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;
    • benefits may be granted for clinical activities undertaken by me, as long as I comply with the laws, registration, formal rules and guidance that apply to such activities;
    • removal from a professional register (even if voluntary) or any restriction in registration should be notified to MDUSL as this may affect membership;
    • 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;
    • I must notify MDUSL in writing of any change in address, country or practice or any other circumstance which may be relevant to membership including if my earnings from non-clinical work will exceed €1,500 in a year;
    • 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.

    I declare that to the best of my knowledge and belief the information provided in connection with this application is true and I have not withheld any material facts.

    How your information will be used

    The Data Controller for your Data is the Medical Defence Union Limited. Our privacy policy sets out, in detail, what personal information we hold about you and how we use it.

    We will use your personal information for the purposes outlined in our 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.

    We may share your personal information with third parties to assist with the provision of these services and only where the law permits.

    Statutory communications

    I 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 me 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 my email address, which may be used for sending electronic mail for the above purposes. Any email address given by me elsewhere on this form is the relevant email address for this purpose, until I notify any change. I understand that if the MDU does not have my email address, I will receive notification by post instead of email
    • notify MDUSL of changes in my email address.

    Further information on electronic 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

    Please read the statement and sign below.

    I am aware that membership does not include indemnity for clinical negligence claims.

    I have read and understood the member guide including the section Benefits of membership - claims made.

    I have read the information about how you use my personal data and understand that it will be used in accordance with the privacy policy. I confirm that the information provided within this form is complete and an accurate representation of my practice.

  • Reason for applying

  • Why have you chosen to apply for MDU membership? Please tick all that apply*
  • How did you hear about us? Please tick all the apply
  • Should be Empty: