Notify Claim / Circumstance

Section 1: Personal Details

Name of Insured Medical Practitioner

Specialty (if applicable)

Your File Reference (if any)

Hospital File Reference (if any)

Name of Hospital / Clinic

Policy Number

Section 2: Patient Details

Full Name

Marital Status

Number of Dependants

Sex

Male

Female

Date of Birth

Occupation

Date(s) of Treatment

Initial / Admission Diagnosis

Section 3: Claimant Details (If Different To Patient)

Full Name

Relationship to Patient

Power of Attorney

Yes

Unknown

Section 4: Incident Details

Date and Place of Incident

Names of All Doctors and Medical Staff Involved

Was the Insured Doctor a hospital employee at the time of the incident?

Names of Any Other Parties Involved

Has the Ministry of Health been notified?

Date on which you first became aware that a claim might occur

Date on which any formal complaint or claim was made, whether verbally or in writing

Date of any court / coronial proceedings which have been served on you

Incident Summary

Section 5: Supporting Documents

Please Indicate The Attachment

Original Complaint Letter(s) / Written Note(s) of Verbal Complaint

Your Responses to Complaint (Including Any Unreleased Drafts)

Hospital Responses to Complaint (If Relevant)

Patient’s / Claimant’s Solicitor’s Correspondence

Issued Court / Coronial Proceedings

Relevant Medical File Extracts

Photographs

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Contact

Ratnawati Osman

Section 1: Personal Details

Section 2: Patient Details

Section 3: Claimant Details (If Different To Patient)

Section 4: Incident Details

Section 5: Supporting Documents

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