Claims history

Please complete the below form, which will help us understand any previous claims history which you may have been involved in.

First Name Last Name GMC Number Email Heath education region

Claims History:

Please note that previous MDDUS members re-applying should disclose incidents that occurred whilst formerly in membership with MDDUS.

Have you ever been refused professional indemnity/insurance or been offered limited or conditional terms by an insurer or defence organisation? Have you been notified of any claim or potential claim in relation to your clinical practice? Please answer “Yes” irrespective of if the claim is settled or did not proceed.

You must tell us if a claim has been intimated against you even if it has subsequently been discontinued or settled and even if you consider that you were not at fault. If you are aware of any incident that you know to be likely to give rise to a claim, you should answer “Yes”

Have you ever been the subject of disciplinary investigation, hearing or other similar action at any place of work?

You must tell us if there has been an investigation into your conduct or competence, even if this did not lead to formal disciplinary proceedings. You do not need to tell us about critical incident investigations that were resolved without criticism of you. If you are in any doubt, you should answer “Yes”

Have you ever been referred to a regulatory body (e.g. the GMC, GDC or NMC or equivalent organisations) or had any conditions imposed on your practice or been suspended or erased from a professional register in any country?

You must tell us about any complaint made to a regulatory body, even if this was resolved without any action being taken against you. If you are in any doubt, you should answer “Yes”

Have you ever been the subject of an adverse finding or criticism within a formal complaints process? Have you ever accepted a police caution, been convicted or otherwise accepted guilt for any criminal offence, anywhere in the world?

You do not need to tell us about motoring offences where you did not attend court, or other convictions that are “spent” or “protected” under the Rehabilitation of Offenders Act (1974) and associated legislation.

Are you aware of any circumstance or situation, relating to professional matters, which you have been involved in and that the MDDUS should be made aware of?

Failure to disclose full and accurate details about previous or current professional problems may invalidate your membership, which could result in you not receiving advice or assistance from the MDDUS.

Please email supporting documents for any incident disclosed to: membership@mddus.com stating your GMC Registration number in the subject line

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Claims history

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