Application for membership

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
Former MDU number (if applicable)
Title*
Forename*
Surname*
Date of birth*

DayMonthYear
Date
Gender*
IMC registration number*
Correspondence Address*
Street address
Street Address Line 2
City*
Email address*
Mobile number (including country code*)*
To delete Mobile number (including country code)
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)?*

YesNo
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?)*

YesNo
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)?*

YesNo
Is your gross annual income from this non-clinical work more than €1500?*

YesNo
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?*

YesNo
Please provide details of the non-clinical work you undertake*
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?*

ConsultantRegistrarMedical officerSenior RegistrarSpecialist Registrar
What speciality do you work in?*
In your state indemnified role, how many hours per week do you work, on average?*

What is your main work address?
Hospital/Clinic name*
Work address line 1*
Work address line 2*
Work address line 3

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)*

DayMonthYear
Date
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.*

Annual Direct DebitDebit/Credit cardBank transfer
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

Please complete all the fields marked *
Type of payment

Recurrent payment
Debtor's Name*
Debtor's Address*
(Mandatory when collecting from a non EEA SEPA country or territory)
City*
Postcode*
Country*
Debtor account number – IBAN*
Debtor bank identifier code – BIC*
Signature*
Please type your full name into the box

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 electronic mail, 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 electronically
- 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.
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

I want a paper copy
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.
Signature*

Clear
Name of submitted form
Should be Empty:

Creditor's Name	Creditor's Identifier	Creditor's Address
MDU SERVICES LTD	IE67SDD993076	ONE CANADA SQUARE

City	Postcode	Country
LONDON	E14 5GS	UNITED KINGDOM

Your details

What is your main work address?

Academic Qualifications

SEPA Direct Debit Mandate

Declaration agreement