Individual Practitioners
Private Practice Proposal Form
When you apply for membership of AOOSIS you will be asked to provide details about the scope of your
practice, the number of sessions you work in the NHS and independent sector and any previous claims against
you. Based on this information your risk will be assessed against standardised criteria and your subscription
rate shall be calculated.
Please ensure you complete and send back the following so that AOOSIS can progress your application:
1) A completed, signed and dated Proposal Form
2) A completed, signed and dated Ophthalmology Addendum
3) A completed, signed and dated Letter of Authority
For enquires about your application, please contact the AOOSIS office on: 0845 094 3915.
Either type in the fields on this form after saving it to your computer, then print out and sign the
form, or print out the form and complete it by hand.
You can e-mail completed forms to: info@aoosis.co.uk
Or you can send them to:
Lucas Fettes & Partners Ltd,
Plough Court,
37 Lombard Street,
London,
EC3V 9BQ
Page 2 of 16
IMPORTANT NOTICE TO THE PROPOSER ABOUT
THE COMPLETION OF THIS PROPOSAL FORM
1. Disclosure
Any “material fact” must be disclosed to Insurers.
A “material fact” is any information which may alter the judgment of an Insurer in assessing the risk.
Any “material change” must be disclosed to Insurers.
A “material change” is any information which may alter the judgment of an Insurer that has not previously
been disclosed as a material fact.
Failure to provide all “material facts” and/or notify all “material changes” may cause the contract of
insurance to be void and may result in Insurers repudiating liability entirely.
2. Presentation
This Proposal Form must be completed in ink by the proposed individual. All questions must be answered.
If there is insufficient space to provide answers additional information should be provided on the proposers
letter headed paper. Where available brochures, standard contract conditions, conditions, agreements and
letters of appointment should be provided.
Failure to present Insurers with information in an appropriate manner may adversely influence the ability
of Insurers to offer terms.
3. Guidance
If in doubt as to the meaning of any question contained within this proposal form or the issues raised in
Disclosure and/or Presentation above, advice should be sought from the AOOSIS office in the first instance by
calling 0845 094 3915.
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 3 of 16
SECTION A – YOUR PERSONAL DETAILS
Title:
Forename(s):
Surname:
Any other name(s) previously used:
Date of Birth:
Nationality:
☐
Male
Female ☐
Home Address
House No.
Address 1:
Address 2:
Address 3:
Address 4:
Town:
Country:
Postcode:
Tel No.
Practice Address:
Line 1:
Line 2:
Line 3:
Line 4:
Line 5:
Town:
Country:
Postcode:
Work No.
Mobile No:
Email address :
Registration Body:
Registration Number:
GMC Registration Date:
Are you on the Specialist Register for
Ophthalmology? Yes ☐
No ☐
SECTION B – ACADEMIC DETAILS
Country of Qualification:
Year of Qualification:
Medical School:
Post Graduate Qualifications:
Are you a Member of the Association of Ophthalmologists Yes
☐
No ☐
Details of NHS position(s) held:
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 4 of 16
SECTION C – ACTIVITIES
1.
Please provide details of the procedures you undertake in private practice on the
Ophthalmic Addendum to this form:
Enclosed ☐
2.
3.
Not Enclosed ☐
Please Provide the % breakdown of your private work between the following categories:
Private Practice
%
Medico-legal reports
%
NHS outsourced work for which you require an indemnity
%
Other
%
TOTAL
%
Please advise the date that you started private practice (month and year)
Month:
4.
Year:
Please advise which Private Hospitals you have admitting rights to:
Hospital 1: ..........
Hospital 2: ..........
Hospital 3: ..........
Hospital 4: ..........
5.
Please state your ESTIMATED TOTAL GROSS ANNUAL INCOME for the year in which you are applying
for indemnity:
Clinical Private Practice
6.
Please state your ESTIMATED TOTAL GROSS ANNUAL INCOME for the year in which you are applying
for indemnity:
Medico-legal work
7.
£
£
Please provide an estimate of the TOTAL NUMBER of PRIVATE PRACTICE procedures /
consultations you undertake per annum: (please note that this should tally with the figures advised in
the Addendum to this form)
Total Number of Private Practice Procedures
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 5 of 16
8.
9.
Please advise an estimated split per annum between the following:
In-Patient Procedures
%
Out-patient Procedures
%
Consultations Only
%
Please give details of the breakdown of your PRIVATE PRACTICE as follows:
Private Hospital
Group
Spire
Proportion of Total Gross
Annual Income
%
Proportion of all Procedures
and Consultations
%
BMI
%
%
Circle
%
%
Nuffield
%
%
Ramsey
%
%
HCA
%
%
Other (please state)
%
%
100%
100%
TOTAL
10. Do you undertake any paediatric work? If so, please advise what proportion of your work this
represents.
Yes ☐
No ☐
If Yes, the proportion is: ............
%
11. Do you own or operate a Hospital, Nursing Home, Clinic, Laboratory, Day Surgical Centre or similar
facility?
Yes ☐
No ☐
If “Yes” please provide full details below.
12. Are you registered as a data controller under the Data Protection Act?
Yes ☐
No ☐
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 6 of 16
13. Do you operate a Limited Company, LLP or similar joint venture?
Yes ☐
No ☐
If Yes, please advise the company name and number.
Company Name
Company Number
a)
Is this purely for fiscal reasons?
Yes ☐
No ☐
b) Does your company employ any staff? (e.g. nurse, secretary)
Yes ☐
c)
No ☐
If Yes, please detail these below:
Are there any other medical or healthcare practitioners associated with your limited company?
e.g. as a director. If yes, please give details below:
Yes ☐
No ☐
14. Do you directly employ or engage any professional staff for whom you are responsible? (i.e not
through your company or any other legal entity)
Yes ☐
No ☐
Name
If “Yes” please provide full details below.
Role
Do they maintain their own indemnity: Yes ☐
Qualifications
No ☐
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 7 of 16
15. Do you undertake any other work for which you require indemnity?
Yes ☐
No ☐
If “Yes” please provide full details below.
16.
16. Are you involved in clinical trials for which you require cover?
Yes ☐
No ☐
If “Yes” please provide full details below.
17. Do you have any high profile clients or undertake work on any high profile people (defined as any
person who is in the public eye or whose income is generated by public / media appearances)
Yes ☐
No ☐
If “Yes” please provide full details below.
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 8 of 16
18. Do you undertake any type of work for any professional sports club or for professional sports
people?
Yes ☐
No ☐
If “Yes” please provide full details below.
19. Are you involved in any clinical activities outside the United Kingdom, the Channel Islands or the Isle
of Man?
Yes ☐
No ☐
If “Yes” please provide full details below.
20. Are you involved in any form of complementary or alternative medicine?
Yes ☐
No ☐
If “Yes” please provide full details below.
21. Do you plan to retire in the next 5 years?
Yes ☐
No ☐
SECTION D – GENERAL QUESTIONS
Please provide the following details in relation to both NHS and PRIVATE PRACTICE:
1.
Are you aware of any complaints or claims that have EVER been brought against you, or any
circumstances which could lead to a complaint or claim against you?
Yes ☐
No ☐
If “Yes” please provide full details on the blank sheet at the end of this form.
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 9 of 16
2.
Are you aware of any circumstances which could lead to disciplinary action or suspension from
practice?
Yes ☐
3.
Are you aware of any circumstance which could lead to an investigation, suspension, the imposition
of conditions or restrictions on your registration or license to practise, or removal from a
professional register of your license, by the relevant registration body?
Yes ☐
4.
No ☐
Have you ever been refused registration or licence to practise or been erased from registration or
has your license to practice been removed by a registration body?
Yes ☐
9.
No ☐
Have you ever been the subject of an adverse finding by a registration body or equivalent in another
country?
Yes ☐
8.
No ☐
Have you ever been subject to any form of investigation by a registration body or equivalent in
another country?
Yes ☐
7.
No ☐
Have you ever had conditions imposed, been suspended or dismissed from practice?
Yes ☐
6.
No ☐
Have you ever been subject to any form of disciplinary action?
Yes ☐
5.
No ☐
No ☐
Have you ever had any restrictions or conditions imposed on your registration or licence to practice
by a registration body?
Yes ☐
No ☐
10. Have you ever been subject to a Medical Defence Organisation’s adverse member procedure?
Yes ☐
No ☐
11. Has any Medical Defence Organisation ever declined to offer you membership, terminate
membership or refused to renew membership?
Yes ☐
No ☐
12. Have you ever been convicted of a criminal offence or received a formal police caution (not spent
under the Rehabilitation Offenders Act 1974?
Yes ☐
No ☐
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 10 of 16
If you have answered “Yes” to any of Section D, please can you provide full details
on the blank page at the end of the form including the following information:
Date of incident(s)

A summary of the events, including all relevant details such
as your involvement.

What action you took, including any involvement from your
indemnity provider

Information on any payments made on your behalf for either
legal costs or indemnity payments
SECTION E – INDEMNITY
Please advise the following:
1.
Please advise the first day that cover is required:
2.
Please provide full details of previous cover – please include all since qualification
Insurer / Indemnity Provider
Limit of
Indemnity
Start Date
£
Current
Subscription
£
£
3.
The standard Limit of Indemnity for AOOSIS members is £10 million for any one claim and in the
annual aggregate, costs inclusive. If you require a higher Limit, please call the
AOOSIS office: 0845 094 3915
4.
What level of Excess would you prefer?
Nil
☐
£5,000
☐
£10,000 ☐
£25,000 ☐
Other, please state £
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 11 of 16
5.
Has prior cover been on a CLAIMS MADE basis?
Yes ☐
6.
No ☐ If “Yes” what are the retroactive dates
Has any proposal for similar insurance or indemnity ever been declined or has such insurance or
indemnity ever been cancelled, refused or had any special terms imposed (other than general market
increases)?
Yes ☐
No ☐ If “Yes” please provide details below
SECTION F – DECLARATION
I have read the AOOSIS Code of Practice and confirm that I comply with its terms in my professional
practice.
I declare that the statements and particulars contained in the proposal are true and that I have not mis-stated
or suppressed any material facts.
I agree that this proposal together with any other information supplied by me shall form the basis of any
contract of insurance effected thereon.
I undertake to inform Insurers of any material change to these facts occurring before completion of the
contract of insurance. However, the duty to disclose material facts continues after the completion of the
proposal form and throughout any period of insurance and any extension thereto, upon which this proposal
form was used as the basis of the contract of insurance.
Signing this proposal does not bind the proposer to complete this insurance.
Signature
Printed name
Date
Data Protection Act – All personal information supplied by you will be treated in confidence by W.R. Berkley Insurance (Europe), Ltd and
will not be disclosed to any third parties except where your consent has been received or where permitted by law. In order to provide you with
products and services this information will be held in the data systems of W.R. Berkley Insurance (Europe), Ltd or our agents or
subcontractor.
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 12 of 16
Please use this space to record the answers to any questions for which you require additional
space, noting the appropriate question number:
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 13 of 16
AOOSIS Ophthalmology Addendum:
Please provide the following details:
1.
Please advise your current training and qualifications
Yes ☐
GMC Specialist Register for Ophthalmology
No ☐
DO date of qualification
MRCOphth date of qualification
FRCOphth date of qualification
Please list any fellowships undertaken giving dates and centres.
2.
Please provide a breakdown of the number of the following procedures you undertake
Private Practice
Cataract Surgery
Corneal Surgery
Laser Refractive Surgery
Strabismus Surgery
Retinal Surgery
Ophthalmic Cancer Surgery
Blepharoplasty (functional)
Blepharoplasty (cosmetic)
Temporal artery biopsies
Skin cancer surgery
Oraya
Medical Opthalmology
Other not listed above. Please elaborate:
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
NHS
Page 14 of 16
DECLARATION
I have read the AOOSIS Code of Practice and confirm that I comply with its terms in my professional practice.
I declare that the statements and particulars contained in the proposal are true and that I have not mis-stated
or suppressed any material facts.
I agree that this proposal together with any other information supplied by me shall form the basis of any
contract of insurance effected thereon.
I undertake to inform Insurers of any material change to these facts occurring before completion of the
contract of insurance. However, the duty to disclose material facts continues after the completion of the
proposal form and throughout any period of insurance and any extension thereto, upon which this proposal
form was used as the basis of the contract of insurance.
Signing this proposal does not bind the proposer to complete this insurance.
Signature
Printed name
Date
Data Protection Act – All personal information supplied by you will be treated in confidence by W.R. Berkley Insurance (Europe), Ltd and
will not be disclosed to any third parties except where your consent has been received or where permitted by law. In order to provide you with
products and services this information will be held in the data systems of W.R. Berkley Insurance (Europe), Ltd or our agents or
subcontractor.
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
Page 15 of 16
AOOSIS Code of Practice
Recurrent themes identified in adverse events reported to AOOSIS have led the Board to develop
the following Code of Practice. Reflecting good ophthalmological practice, AOOSIS members are
expected to adopt the code into their practice to reduce avoidable harm to patients.
Pre-operative assessment
The ophthalmologist assuming responsibility for a patient’s care should ensure the patient’s
suitability for surgery, and any anaesthetic required, or arrange referral to a suitably qualified
colleague where necessary.
Consent
Good surgical practice requires ophthalmologists to ensure that proposed treatments, their risks and
benefits, available alternatives, and post-operative care are all discussed in detail. Where possible,
patients should be given at least several days to reflect on their treatment options before
committing to surgery. Generally, this would mean that the surgeon should not meet the patient for
the first time on the day of surgery. However, the Board recognises that for some patients, eg those
coming from abroad, circumstances may be exceptional requiring treatment to be arranged more
quickly.
No inducements
No financial or other incentives should be offered to patients to agree to sign up to treatments.
Continuity of care
In general, the responsible surgeon should oversee the pre-operative assessment, consent process,
surgery and post-operative care. Where responsibilities are delegated to other surgeons,
optometrists, or others, the surgeon must be satisfied that the individual concerned possesses the
appropriate level of experience and expertise.
Expertise and facilities
Members undertaking surgery must have the necessary expertise to complete the procedure to a
reasonable standard and to manage reasonable foreseeable complications that may occur. The
facilities equipment and assistance must also be adequate to manage any complications that may
occur during or after surgery.
Access to emergency advice and assistance
Patients should have immediate access, in the event of concerns or complications, to the surgeon
who undertook their surgery or a deputy with the same experience and expertise to ensure that all
potential problems are adfdressed satisfactorily.
Clinical records
An adequate record of all patient contacts should be made in the patient’s clinical records.
Lucas Fettes & Partners Ltd is authorised and regulated by the Financial Conduct Authority.
FCA Registration Number: 304899
Plough Court, 37 Lombard Street, London, EC3V 9BQ
0845 094 3915
info@aoosis.co.uk
www.aoosis.co.uk
Date: ……………………………….
TO WHOM IT MAY CONCERN
Dear Sirs
LETTER OF AUTHORITY TO REPORT
This letter is to confirm that I have authorised the appointed brokers for AOOSIS, Lucas Fettes
and Partners, of Plough Court, 37 Lombard Street, London, EC3V 9BQ to report on malpractice
insurance on my behalf.
Please provide Lucas Fettes and Partners with any documentation they may require including, if
requested, Confirmed Claims Experience, copy Proposal Forms and copy Policy Documents.
Yours faithfully,
Name: ……………………………………………………
GMC Number: ……………………………………….
7 Blighs Walk, Sevenoaks, Kent TN13 1DB
AOOSIS is a company limited by guarantee registered in England and Wales. Company Number 7398533.
AOOSIS is an Introducer Appointed Representative of Lucas Fettes & Partners Limited.
Lucas Fettes & Partners Limited is an Independent Insurance Intermediary authorised and regulated by the Financial Conduct Authority.