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Locum Professional Indemnity Insurance

General questions and details

Your insurance

Payment Information

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General questions and details

Important Information – Please read the Important Information below, Important Note and the fact sheet Information about our Insurance Services before completing this form.

1. Your cover will not start until we have accepted this application. We reserve the right to refuse acceptance of any application for insurance. No liability is undertaken by us in connection with this proposal until cover has been issued with our authority.

2. By completing this application, you consent to accept the Insurance Policy Terms & Conditions. A copy of the Policy Document is available on request. You also agree that you have read the policy summary and the leaflet about our insurance services.

* Title

* First name of Proposer

* Surname of Proposer

* Postal Address line 1

Postal Address line 2

* Town/City

* Postcode

* Home/Evening Tel No.

Fax No.

* Mobile/Daytime Tel No.

* Email Address

* Date of Birth

* GPhC/PSNI Reg No.

* Date when you registered with the GPhC

* Date you wish this insurance to commence

* Where did you hear about NPA Insurance Ltd?

* Which cover would you like (see below to find out which cover is applicable to you)?

For the purposes of this proposal your profession is described as follows:

Locum Pharmacist
Full or part-time, employed or self-employed engaged in community pharmacy and/or work as a Hospital pharmacist. All other activities including consultant pharmacy work are excluded.

Premium for Professional Indemnity & Legal Expenses (inclusive of IPT) is £125 per year.

Additional Premium Payable for Independent Prescribing is £159 (Total payable is £284 inclusive of IPT)

General questions

*1. Are you ever engaged in hospital work?

If yes, please include details

*2. Are you ever engaged in consultancy work (primary or otherwise)?

If yes, please include details

*3. Are you ever engaged in extended or 'new' role activities (including PACT analysis, formulary development precribing analysis, clinic administration or non-dispensing services)?

If yes, please include details

*4. Are there any claims or prosecutions currently being made against you alleging negligent act, error or omission, which may genuinely and reasonably be expected to result in a claim?

If yes, please include details

*5. Are you aware of any circumstances which have already occurred which might genuinely and reasonably be expected to result in a claim?

If yes, please include details

*6. Are you aware of any circumstances which have already occurred which may give rise to your involvement in a legal dispute?

If yes, please include details

*7. Have you ever been involved in a malpractice liability, professional indemnity or public liability claim in the past?

If yes please include details of the claim, including the circumstances, date, the name of the Pharmacist employing you and payments made.

*8. Are you currently, or have you ever in the past, been subject to any investigation or disciplinary procedures by the GPhC, PSNI or other bodies?

If yes, please include details

*9. Have you had similar insurance previously?

If yes please give details below (insurance company and policy number)
Insurance company namePolicy number

*10. Have you ever been refused similar insurance, been quoted increased premiums or had special conditions imposed?

If yes, please include details

*11. Have you ever been or do you have reason to expect to be bankrupt, insolvent or subject of a CCJ?

If yes, please include details

*12. Have you ever been or do you have reason to expect to be director of a liquidated Company?

If yes, please include details

*13. Have you ever been or do you have reason to expect to be convicted of or charged (but not yet tried) with a criminal offence?

If yes, please include details

*14. Have you ever been or do you have reason to expect to be prosecuted for Health and Safety offences?

If yes, please include details

Important Notes

Before you complete the following declaration, please make sure that you have answered all the questions relating to the cover and not deliberately ignored information. It is essential that you disclose accurately all facts which influence acceptance of this application or terms to be applied. If you are not sure whether to include certain information, please do so anyway. If you do not tell us something relevant, your insurance may not be valid.

*Declaration

I declare that to the best of my knowledge and belief, the information provided which I have read and checked is true, accurate and complete. I am willing to accept the terms and conditions of NPA Insurance Ltd policy and I undertake to pay the premium when called to do so.

I agree

Insurance is subject to terms and conditions. NPA Insurance Ltd. Registered in England 64269. Mallinson House, 38-42 St Peter's Street, St Albans, Herts, AL1 3NP. Authorised and regulated by the Financial Services Authority and is entered into their register www.fsa.gov.uk . Firm number 202069.

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NPA Insurance Ltd. Registered in England. No. 64269.
Registered Office: Mallinson House, 38-42 St. Peter’s Street, St. Albans, Herts, AL1 3NP.

Authorised and regulated by the Financial Services Authority. FSA Registration Number 202069. The FSA register can be accessed at www.fsa.gov.uk/register.
NPA Insurance is a member of the Association of British Insurers.

Not all products available in all territories. Calls may be recorded. Insurance subject to terms and conditions.