| Date of Birth |
|
| Nationality |
|
| Gender |
Male
Female |
| Registration Body |
|
| Registration Number |
|
| Registration date |
|
| Registration type |
Full
Limited
Provisional
|
1) Are you involved in any cosmetic procedures, surgical procedures not on the minor surgical list? (If 'yes' please provide full details and of time spent undertaking each of these procedures.)
Yes
No
|
| Details |
|
2) Do you undertake any other work for which you require indemnification for? (If 'yes' please provide full details.)
Yes
No
|
| Details |
|
3) Are you a Dentist with Special Interests? (If 'yes' please state your speciality and provide details of the work you carry out, including where (e.g. for other practices))
Yes
No
|
| Details |
|
4) Do you undertake any other work for which you require indemnification for (e.g. Company Doctor)? (If 'yes' please provide full details.)
Yes
No
|
| Details |
|
6) Do you undertake any out of hours work? (If 'yes' please advise how many sessions per month.)
Yes
No
|
| Details |
|
7) Do you own or operate a Hospital, Nursing Home, Clinic, Laboratory, Day Surgical Centre or similar facility? (If 'yes' please provide full details.)
Yes
No
|
| Details |
|
8) Are you involved in any activities that require you to travel outside the United Kingdom, the Channel Islands or The Isle of Man? (If 'yes' please provide full details.)
Yes
No
|
| Details |
|
| 10) Do you plan to retire in the next 5 years? |
Yes
No
|
| 11) Please advise the first day that cover is required? |
|
12) Have you ever had your professional registration suspended, erased or made conditional? (If 'yes' please provide full details.)
Yes
No
|
| Details |
|
13) Have you ever had or aware of any complaint, claim, circumstance that may be brought against you? (If 'yes' please provide full details.)
Yes
No
|
| Details |
|
| 14) Please provide full details of previous cover – please include all since qualification.
|
| Company |
|
| Start date |
|
| End date |
|
| Company |
|
| Start date |
|
| End date |
|
| Company |
|
| Start date |
|
| End date |
|
Authorised and regulated by the Financial Services Authority (309026)