HR and Employment Advisory product application form

Thank you for choosing to apply for our HR and Employment Advisory product.

We rely on the information in this proposal form in deciding whether to offer you membership, how to set the terms on which we would implement the HR and Employment Advisory product and the subscription to be charged.

When completing the form, please ensure the you:

Give fair representation of the risk to be indemnified by clearly disclosing all material facts and circumstances (whether or not subject to a specific question) which you, your senior management and those responsible for arranging this subscription, know or ought to have known following a reasonable search. If you are in any doubt as to whether a fact or circumstance is material, it should be disclosed;

Take care to ensure that all information provided is correct, accurate and complete

Review your current indemnity to identify any duplication.

If you require further information, call our membership services department on 0333 043 0000 or email membership@mddus.com

Requested start date

The start date requested must not be more than two months in advance. Please note: If the quote is not accepted by the start date provided, or 60 days from the date this document was signed, you will be required to complete a new proposal form.

Name of practice Registered address Town Postcode Contact name / Practice Manager Group scheme number (if applicable) Email address Number of individuals employed by the medical or dental business Would you like a quote for: Has the practice ever been involved in an employment tribunal case, whether settled before tribunal or otherwise. Yes No If Yes, please provide details Are you aware of any employment disputes in the practice that are currently ongoing?: Yes No If Yes, please provide details I wish to pay the subscription amount by:

HR and Employment Advisory product application form

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