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General Information
Regulated firm
(Required)
Professional Dental Indemnity (PDI) acts as an Introducer Appointed Representative for All Med Pro (All Medical Professionals Limited). This means that as the regulated principal firm, All Med Pro is responsible for offering advice and recommendations regarding your medical indemnity insurance. This proposal will be sent directly to All Med Pro and you will receive your quotation directly from All Med Pro.
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Profession
(Required)
Please select..
Dentist
Dental nurse
Dental therapist
Dental hygienist
Orthodontic therapist
Dental technician
Foundation Dentist
Other
Other
Where did you hear about us?
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ADI
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Recommended
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Social Media
Other
Other
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What month is your indemnity due?
January
February
March
April
May
June
July
August
September
October
November
December
Full Name
(Required)
Title
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First
Last
Phone
(Required)
Email
(Required)
Address
(Required)
First Line of Address
Town
Postcode
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Is your correspondance address any different to the above?
Please select Yes or No
Yes
No
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Address
(Required)
First Line of Address
Town
Postcode
Claims and Conduct
Please read the following questions carefully and answer all of them fully and truthfully.
1 - Have any complaints or claims been made, brought or threatened against you?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances, dates and costs
2 - Are you aware of any acts, errors, omissions, incidents, events, circumstances or requests for notes which may give rise to a complaint or claim against you?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances, dates and costs
(Required)
3 - Are you aware of any complaints, claims, acts, errors, omissions, incidents events or circumstances which may lead to an investigation, suspension, the imposition of conditions or restrictions on your registration or license to practice or your removal from a professional register or the removal of your license by a relevant registration body?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances, dates and costs
(Required)
4 - Are you aware of any complaints, claims, acts, errors, omissions, incidents, events or circumstances which may lead to disciplinary actions or suspension of practice?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above
(Required)
5 - Have you ever been subject to any form of disciplinary action?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
6 - Have you ever had conditions to practice, been suspended or restricted from practice or dismissed from practice?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
7 - Have you ever been subject to any form of investigation or adverse finding by a registration body or equivalent in any country?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
8 - Have you ever been admitted to or sought treatment from any mental health or chemical / substance abuse programme?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
9 - Have you ever been refused registration or license to practice or been erased from registration or had your license to practice suspended or removed by a registration body?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
10 - Have you ever had any restrictions or conditions imposed on your registration or license to practice by a registration body?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
11 - Have you ever been the subject of a Medical Defence Organisation’s adverse member procedure?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
12 - Has any Medical Defence Organisation ever declined to offer you membership, terminated or restricted your membership or refused to renew your membership?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
13 - Has any insurance indemnity provider ever declined to insure you, imposed special terms, cancelled or refused to renew your insurance?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
14 - Are you being investigated, or have you ever been convicted of a criminal offence or received a formal police caution (not spent under the Rehabilitation of Offenders Act 1974) in any country?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
15 - Have you ever suffered a loss of personal information as a result of a privacy breach?
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
16 -Have you ever suffered a loss through the fraud or dishonesty of any other person(s) or are you aware of any matter which may lead to a claim against your employees such as staff, associates, dental nurses etc.
(Required)
Please select Yes or No
Yes
No
Please provide further details on the above including circumstances and dates
(Required)
Do you provide any prison service work?
(Required)
Yes
No
You and Your Practice
Date of birth
(Required)
DD slash MM slash YYYY
How many sessions per week do you work?
(Required)
Please enter a number less than or equal to
14
.
What is the total annual fee income derived from your dental activities?
(Required)
In which country did you qualify?
(Required)
Select country
United Kingdom
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
What year did you qualify?
(Required)
Please enter a number from
1900
to
2030
.
What is your GDC registration number?
(Required)
Are you a practice owner?
(Required)
Please select Yes or No
Yes
No
Will you be retiring in the next 5 years?
(Required)
Please select Yes or No
Yes
No
What date are you looking to retire?
DD slash MM slash YYYY
Are there or have there been any conditions or interruption attached to your GDC registration?
(Required)
Please select Yes or No
Yes
No
Please provide additional information in respect to your GDC registration
(Required)
Please select your previous indemnity providers
Dental Protection
DDU
MDDUS
Hiscox
InSync
MIAB
Towergate
MMI4U
DIA
Other Provider
No Previous Insurance
Dental Protection
(Required)
Please provide the dates that you were covered with Dental Protetcion
DDU
(Required)
Please provide the dates that you were covered with DDU
MDDUS
(Required)
Please provide the dates that you were covered with MDDUS
Hiscox
(Required)
Please provide the dates that you were covered with Hiscox
InSync
(Required)
Please provide the dates that you were covered with InSync
MIAB
(Required)
Please provide the dates that you were covered with MIAB
Towergate
(Required)
Please provide the dates that you were covered with Towergate
MMI4U
(Required)
Please provide the dates that you were covered with MMI4U
DIA
(Required)
Please provide the dates that you were covered with DIA
Other Indemnity Provider
(Required)
Please provide the dates that you were covered with other indemnity providers including the providers name
What date do you require the policy to incept/start?
DD slash MM slash YYYY
Has prior cover been on a “Claims Made Basis”?
Please select Yes, No or Unknown
Yes
No
Unknown
If you know your retroactive date please provide
DD dot MM dot YYYY
Has there ever been any gaps in your indemnity coverage?
(Required)
Please select Yes or No
Yes
No
Please provide full details of any gaps in coverage including dates
(Required)
Do you have an updated claims history or letter of good standing from your previous indemnity provider(s)?
(Required)
Please select Yes or No
Yes
No
Letter of Good Standing
Please upload your letter of good standing if you have it to hand
Drop files here or
Select files
Max. file size: 60 MB.
Clinical Activities
Please select your clinical activities
(Required)
General Dentistry
Orthodontics
Implantology
Oral or Maxillofacial Surgery
Facial Aesthetics (Botox and fillers)
Cosmetic Dentistry
Surgical Periodontal Procedures
What % of your time is spent on General Dentistry?
(Required)
Please enter a number less than or equal to
100
.
What % of your time is spent on Orthodontics?
(Required)
Please enter a number from
1
to
100
.
What % of your time is spent on Implantology?
(Required)
Please enter a number from
1
to
100
.
What % of implants involve sinus lifts?
Please enter a number from
0
to
100
.
What % of your time is spent on Facial Aesthetics?
(Required)
Please enter a number from
1
to
100
.
What % of your time is spent on Oral or Maxillofacial Surgery?
(Required)
Please enter a number from
1
to
100
.
What % of your time is spent on Cosmetic Dentistry?
(Required)
Please enter a number from
1
to
100
.
What % of your time is spent on Surgical Periodontal Procedures?
(Required)
Please enter a number from
1
to
100
.
Total Clinical Split Percentage %
(Required)
Must equal 100%
Are general anaesthetics ever administered?
Yes
No
Facial Aesthetics
Please provide the annual number of botox procedures
Please provide the annual number of collogen fillers
Please provide the annual number of facial peels
Please provide the annual number of other
Your Cover
What level of indemnity cover do you require?
(Required)
£2,000,000
£5,000,000
£10,000,000
Addendum
Please select any oral or maxillofacial surgery that you undertake.
Dento-alveolar procedures - Surgical treatment of disorders of the teeth and their supporting hard and soft tissues.
Apicectomies
Exodontia (eg, wisdom teeth removal)
Benign cyst removal
Minor pre-prosthetic surgery
Tooth transplantation
Surgical removal of teeth
Removal of impacted or ectopic teeth, including wisdom teeth
Removal of developmental abnormalities of the teeth and jaws
Benign jaw growth removal
Dental implants (excluding sinus lifts or bone augmentation which involves the floor of the sinus, or extra-oral bone harvesting, all of which are regarded as maxillofacial procedures).
Dental implants (including sinus lifts or bone augmentation which involves the floor of the sinus, or extra-oral bone harvesting, all of which are regarded as maxillofacial procedures).
Trauma - Rhinoplasty, pinnaplasty, genioplasty
Facial aesthetics - Rhinoplasty, pinnaplasty, genioplasty
Cleft lip and palate
Head and neck cancer
Craniofacial surgery - Craniosynostoses, Craniofacial dysostoses, Orbital
Skull base surgery
Orthognathic surgery
Select All
Are you a member of the British Association of Oral and Maxillofacial surgeons?
(Required)
Please select Yes or No
Yes
No
Are you a member of any other professional organisation?
(Required)
Please select Yes or No
Yes
No
Do you personally administer general anaesthetics?
(Required)
Please select Yes or No
Yes
No
Do you have the relevant post-graduate training and experience to administer general anaesthetics?
(Required)
Please select Yes or No
Yes
No
Is the general anaesthetic administered by a dentist or medical practitioner with the appropriate post-graduate training and experience?
(Required)
Please select Yes or No
Yes
No
Does the person administering the general anaesthetics (the Anaesthetist) always remain with the patient throughout the procedure and until the patient's protective reflexes have returned and the patient has gained control of their own airway?
(Required)
Please select Yes or No
Yes
No
Does the Anaesthetist always have an assistant in support throughout the procedure and recovery?
(Required)
Please select Yes or No
Yes
No
Is sedation ever administered?
(Required)
Please select Yes or No
Yes
No
Is the IV sediation administered by you?
(Required)
Please select Yes or No
Yes
No
What type of practitioner is the IV sedation administered by?
(Required)
General Anaesthetics
What type of sedation is administered?
(Required)
Intravenous
Inhalation / RA
Is the operating room equipped with continuously-acting monitoring devices and a defibrillator?
(Required)
Please select Yes or No
Yes
No
Is there basic life support equipment set up in the operating room?
(Required)
Please select Yes or No
Yes
No
Is the patient's full medical history always taken prior to administration of general anaesthetics/sedation?
(Required)
Please select Yes or No
Yes
No
Marketing Consent
(Required)
By ticking yes, you consent to receive email updates and other marketing communications from All Med Pro. We respect your privacy and will never share your information with third parties without your explicit consent. You can unsubscribe at any time by clicking the link provided in our emails. For more information on how we use and protect your data, please refer to our Privacy Policy.
Yes, I would like to receive email updates and marketing communications from All Med Pro.
No, I would not like to receive email updates and marketing communications from All Med Pro.
Declaration
(Required)
You declare and warrant that after enquiry all statements and particulars contained in this Proposal and addendum are true and that no information whatever has been withheld which might increase the risk of The Company or influence the acceptance of this Proposal and should the above particulars alter in any way you will advise The Company as soon as practicable.
You understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of this Proposal may result in The Company refusing to provide indemnity or voiding the Policy in every respect. You hereby agree and accept that this Declaration shall be the basis of the contract between both parties if entered into.
You confirm that as of the date hereof you have appointed All Med Pro as your exclusive Insurance Broker with respect to the above coverage. The appointment of All Med Pro rescinds all previous appointments and the authority contained herein shall remain in full force until cancelled in writing.
I agree to the above declaration
What is your current renewal premium?
(Required)
Please can you advise where you heard about us?
(Required)
If you wish to supply additional information please provide below
Supporting Information
You may wish to supply supporting information such as your CPD log
Drop files here or
Select files
Max. file size: 60 MB.
Home
About Us
Benefits
Testimonials
Practice Insurances
Education & Events
Home
About Us
Benefits
Testimonials
Practice Insurances
Education & Events
Get A Quote
Home
About Us
Benefits
Testimonials
Practice Insurances
Education & Events
Home
About Us
Benefits
Testimonials
Practice Insurances
Education & Events
Get A Quote