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To be completed by the Authorised Person(s) set out in the Proposal Form / Renewal Questionnaire. The Insurer cannot accept submissions from unauthorised contacts. We require the information set out in this form in order to check whether what you are reporting is covered by your Policy and for compliance with Practice directions and Pre-action Protocols issued and approved from time to time by the Civil courts.

If you require more space for any of the answers, please use the ‘Further comments’ field in each section. If you need any help completing this form, please contact Healthcare Protection for guidance on 800905727.

Please email any additional information to [email protected]

Adverse incident notification

An adverse incident is an event or circumstance that could reasonably be expected to give rise to a claim, complaint or allegation against the Insured. Please complete all the requested details in this section to report an adverse incident.

* denotes a required field.

Your details

Title *

First name *

Last name *

Postition *

Preferred contact number *

Email address *

Policy details

Insured *

Policy number *

Incident details

Individual employee and/ or location *

Date the adverse incident occurred *

Date the Insured became aware that the adverse incident occurred *

Was any incident reporting documentation completed? *

If yes, please provide the date and please supply a copy

If the incident occurred prior to insuring with MPSUW, has the Insured notified a previous insurer?

Practitioner(s) and other parties involved in the incident/ treatment:

Practitioner / other party 1

Name and title

Employee / independent contractor

Employer name

Professional body (please specify) registration number

Indemnifier / insurer

Policy number

Cover in place?

Practitioner / other party 2

Name and title

Employee / independent contractor

Employer name

Professional body (please specify) registration number

Indemnifier / insurer

Policy number

Cover in place?

Practitioner / other party 3

Name and title

Employee / independent contractor

Employer name

Professional body (please specify) registration number

Indemnifier / insurer

Policy number

Cover in place?

Practitioner / other party 4

Name and title

Employee / independent contractor

Employer name

Professional body (please specify) registration number

Indemnifier / insurer

Policy number

Cover in place?

If there are additional parties involved, please provide information under the Further comments section below

Please provide details of the event or circumstance (brief description of facts/ type of injury sustained) being reported. Please refrain from offering any view about fault, blame or liability

Enter details below *

To insert a line break please use Shift+Return keys together.

Patient's details

Initials of the patient *

Please do not include the full name of the patient due to data protection requirements

Patient's gender *

Patient's date of birth *

Patient reference number at the practice/ hospital (if applicable)

Patient's present condition and prognosis (if known)

To insert a line break please use Shift+Return keys together.

Further comments and supporting documentation

Please enter any further comments

To insert a line break please use Shift+Return keys together.

Important note

We may request copy correspondence pertaining to the adverse incident, together with redacted documentation and Medical/ Dental records relating to the treatment in question to be sent to us securely.

The Insured is respectfully reminded of the Policy’s terms and conditions, and accordingly that no details of the Policy may be disclosed, nor may liability be admitted, arrangement, offer, promise or payment be made, or cost or expense incurred by the Insured without the written consent of the Insurer.

The Insured’s attention is also drawn to the requirement under the Policy to provide Healthcare Protection with IMMEDIATE NOTICE OF CLAIMS OR CIRCUMSTANCES which may give rise to a claim; notice must be made as soon as reasonably practicable within the policy period (or within 30 calendar days of the policy expiring). Accordingly, if the Insured is unable to complete all sections of this form, this should not delay its dispatch to the Insurer and any further information or material can be provided as soon as possible thereafter.

Declaration

Please check the box below *

On behalf of the insured I confirm I have only provided the information specifically requested and have not provided any additional details which would allow MPSUW Limited to identify an individual patient.

Adverse incident notification

Adverse incident notification

Your details

Policy details

Incident details

Further comments and supporting documentation

Declaration

Contact us

Select location

New customers

Existing customers

General