Microsoft word - micropigmentation training proposal _novae_

MALPRACTICE, PROFESSIONAL INDEMNITY, PUBLIC & PRODUCTS LIABILITY
INSURANCE SCHEME
TO ARRANGE COVER, FOLLOW THESE INSTRUCTIONS:
The policy is written on a "Losses occurring" basis, so as long as the policy is in force when the
incident happened, then subject to the policy wording, terms and conditions the claim will be dealt
with by your insurers. The policy includes full retroactive cover
You must hold a qualification recognised by Holistic Insurance Services. Complete the proposal form and include all documentation Enclose your payment for the correct premium
Enclose copies of your Qualification Certificates
Holistic Insurance Services 181A Watling Street West, Towcester, Northants NN12 6BX
ANNUAL PREMIUMS:
Malpractice, Professional Indemnity, Public &
Limit of indemnity
Products Liability*
Micropigmentation
Legal defence costs in respect of claims made Legal defence costs in respect of disciplinary hearings; Legal/accountancy costs incurred as a result of an Inland Revenue or VAT investigation Limit of indemnity £500,000 (please note that there is an inner limit of £100,000 for each claim) *** Optional Cover
Business Equipment*
* Terms and conditions apply. A copy of the policy wording is available upon request. *** This section is underwritten on a “Claims Made” basis and therefore must be in force at the time a POLICIES ARE ISSUED ON A 12 MONTH BASIS. REFUNDS ARE NOT GIVEN AFTER THE FIRST 30 DAYS OF COVER DUE TO THE NATURE OF THE INSURANCE. THESE RATES ARE VALID TO 28TH FEBRUARY 2011 Holistic Insurance Services, 181A Watling Street, Towcester, Northants, NN12 6BX
Tel: 0845 222 2236
Fax: 0845 222 2237
www.holisticinsurance.co.uk

The following cover restriction will apply to your policy:
Micropigmentation/Micropigmentation pigment removal and correctional
procedures
B) Pigments which are not supplied by an identifiable source. The supplier must be noted on the consultation record card. C) Persons who the insured is aware i) are haemophiliac ii) are pregnant or nursing iii) are under the influence of alcohol or drugs iv) have Hepatitis C v) are five weeks pre or post radiotherapy/chemotherapy treatment unless medical consent is given vi) are epileptic and have experienced a seizure in the last two years. vii) those taking Warfarin unless medical consent is given viii) those using Antasuse and Roaccutane within 6 months of the treatment date ix) those with visible evidence of a cold sore or fever blister or a skin disorder on the area to be treated. D) Persons who have not signed a consent form It is a further condition of this insurance that all clients declaring any medical condition or are taking prescribed medication must sign a consent form that they understand how their condition or medication may affect the treatment including bruising, bleeding and additional healing time. E) Those who have not been offered a patch test and have not signed the consent form to state that they have been offered but refused a patch test. For those undertaking a patch test a period of 2 hours should be allowed in between the patch test and the treatment. F) The use of a laser for correction procedures. G) The use or removal of indelible inks. H) The application or removal of body tattoos. This does not apply to paramedical tattooing. All other terms, conditions, exclusions and limitations in this policy remain unaltered. Holistic Insurance Services, 181A Watling Street, Towcester, Northants, NN12 6BX
Tel: 0845 222 2236
Fax: 0845 222 2237
www.holisticinsurance.co.uk
INSURANCE PROPOSAL FORM
Malpractice/Professional Indemnity/Public/Products Liability Insurance

Please complete in blue or black ink. Make sure that everything is legible. This form is scanned
electronically. Please answer all questions. No Insurance is in force until confirmation has been
given. The completion of this form does not bind either you or the insurer in contract.
Name including any trading name
and title (Mr/Mrs/Ms/Miss)
Correspondence Address
Postcode
Telephone Number
Email address
Therapies that you wish to cover: Please enclose a copy of your qualification
certificate/diploma
Please use a separate sheet if you have more therapies that you require cover for. Some therapies not included on the approved therapies list may require an increase in premium. Do you maintain client’s records and retain them for at least 7 years? □ Yes □ No Are you a member of any Professional Organisation? If yes, please list Have you ever been subject to a disciplinary hearing or suspended from any Do you carry or have you carried Professional Indemnity Insurance during the last 12 months A) Have you had any claims or suits for negligence, errors or omissions been made against you or are you aware of any circumstances which may result in any such claims being made against you □ Yes □ No B) Has any Insurer ever cancelled, declined refused to renew or accepted on special terms your professional insurance □ Yes □ No C) Have you ever been convicted of, or cautioned for (or charged but not yet tried with) any criminal offence (other than motoring offences)? □ Yes □ No If yes to questions A, B or C above, please give full details on a separate sheet and you will be contacted. Date Insurance to commence I hereby declare and warrant the above statements and particulars are in all respects complete and true, that they are material, and that I have not suppressed or misstated any material facts and I agree that this proposal form shall be the basis of the contract with the underwriters and deemed to be part of the insurance coverage issued to me. Signature of Proposer …………………………….……. Date ……………………………. We cannot accept any proposal form which is signed/dated more than 30 days prior to the commencement date. Please forward all documentation to:
Holistic Insurance Services, 181A Watling Street West, Towcester, Northants. NN12 6BX
Telephone number 0845 222 2236 Fax Number 0845 222 2237
METHODS OF PAYMENT (Please tick chosen option):
□By cheque, bank draft or postal order - made payable to Holistic Insurance Services. If you
are based in Eire, payment must be in EUROS not Sterling
□By debit/lazer card
□By credit card (Visa or Mastercard only)
Note a fee of 2.5% is added to credit card payments
Card number: Expiry date: ___/___ Issue number (Switch only) ____ Card security code: Please make payment with order: we will not cash your payment unless your application is approved. Please allow up to 5 - 10 days for processing. Holistic Insurance Services is a trading name of GINS Ltd
Authorised and Regulated by the Financial Services Authority

The insurance is underwritten by Novae Underwriting Limited underwriting
for certain underwriters at Lloyd’s

Source: http://www.annettepower.co.uk/files/micropigmentation.pdf