Application Form

British Society of Echocardiography
Medical Malpractice & Public Liability Insurance Application Process

You must be a member of the BSE to use this facility.

How to Apply:

  • 5. Complete the form below
  • 6. Click the “SUBMIT” button and this will email the complete form to FOCUS
  • 7. You will receive an e-mail back confirming reciept of your application

If any answers are not applicable please complete as NONE or N/A – do not leave blank

Fields marked with an * are required

4. Contact Details

Correspondence Address incl postcode:

Registered Address incl postcode, if a Ltd Company:


 e.g. “Patient reports are kept at the private clinics I work at and held for 7  years. Reports are kept on a local server with hard copies in Consultant files”

PLEASE NOTE IT IS A REQUIREMENT OF THIS POLICY THAT ALL RECORDS ARE RETAINED FOR A MINIMUM PERIOD OF 10 YEARS, AND IN THE CASE OF MINORS, 10 YEARS FROM MAJORITY

9. What is the total gross annual income from your private work activities:


PREVIOUS CLAIMS HISTORY

10. i) List all claims made against you during the last 10 years. IF NONE, PLEASE STATE “NONE”:


ii) List all circumstances/complaints which may give rise to a claim being made against you. IF NONE PLEASE STATE “NONE”


Declaration

I/we declare and warrant that after enquiry all statements and particulars contained in this proposal and addenda are true and that no information whatsoever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this Proposal and should the above particulars alter in any way I/we will advise the Underwriters as soon as practicable. I/we understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of the Proposal may result in the Underwriters refusing to provide indemnity or voiding the policy in every respect.

I/we hereby agree and accept that this Declaration shall be the basis of the contract between both parties if entered into.


DEBIT/CREDIT CARD AUTHORISATION/PAYMENT OPTIONS

Please note WE DO NOT ACCEPT American Express cards

  • Instalments MAY be available on request for premiums over £1,000 - 10 monthly instalments subject to a 7.5% credit charge via Close Premium Finance

Definitions:

  • NON-INVASIVE includes Pacing Follow-up & Implantable Cardioverter Defibrillation Follow-up
  • INVASIVE covers non-invasive(as above) plus Contrast Agent Echos &/or Dobutamine Stress Echos

MAKING PAYMENT

We will call you upon receipt of this application to obtain your Credit/Debit card details or, if paying by instalments, your Bank Account details

BY PRESSING THE SUBMIT BUTTON YOU ARE AGREEING TO PROCEED WITH THIS INSURANCE AND CONFIRMING YOU HAVE READ THE FOCUS TERMS OF BUSINESS

Thank You

FOCUS Oxford Risk Management Ltd is authorised and regulated by the Financial Conduct Authority. FCA Registered No. 773843

Registered address is 1 Golden Court, Richmond, Surrey, TW9 1EU. Registered in the England & Wales No. 10428089

‘FOCUS’ is a trading name of FOCUS Oxford Risk Management Ltd

Novae Underwriting Limited is authorised and regulated by the Financial Conduct Authority, FRN 311833

The company is a Lloyd’s service company and acts for certain underwriters at Lloyd’s

Registered Office: 71 Fenchurch Street, London EC3M 4HH. Company No. 3043816 England. VAT Reg No. 668 2895 74