MEDICAL MALPRACTICE INSURANCE PROPOSAL FORM.
PART 1: GENERAL SECTION
- You are required to disclose all material information, relating to this application. You are also required to disclose any facts or conduct which might lead to a claim being made against you. Failure to do so may affect your cover.
You will be bound by the answers and information you provide in this proposal form
This proposal form will be submitted on your behalf to the Insurer and has been compiled in such a manner as to provide the Insurer with as much detail as possible to enable them to evaluate the risk.
•Completion of this form does not bind either party to conclude the insurance transaction.
•To assist the Insurer in accurately assessing liability for rating purposes, you are requested to answer all the questions. Where a mark is required, please mark the appropriate box with an “X”. Replies such as “see your records”, or “as previously advised” will not be accepted. If the space provided is insufficient, a separate sheet should be attached.
•You acknowledge that the personal information supplied is provided voluntarily and therefore constitutes specific, voluntary consent to the processing of such information by the Insurer.
•Your personal information will be processed for:
a. General and specific underwriting and risk assessment purposes.
b. Statistical research and / or reporting.
c. The legitimate interests of the Insurer and/or yourself and
d. Any statutory or regulatory compliance (where applicable).
•You have the right to request access to, and correction of, your personal information.
•You can instruct the insurer to cease the processing of your personal information at any time and, subject to the requirements of applicable South African laws, request that the Insurer delete and/or de-identify such personal information.
Privacy and Sharing of Information
Shomang Brokers is committed to the principles of privacy and protection of information in our engagement with clients & stakeholders. Shomang Brokers will not sell, rent or lease your personal information.
We may also collect personal information from other commercially available sources that we deem credible.
We may disclose your personal information to insurance companies, product suppliers and third-party service providers. This will be done only for the purpose of providing you with financial services.
By signing this form, you consent to Shomang Brokers or Insurers processing, sharing and retaining your personal information whether your policy is active or has been cancelled.