Indemnity enquiry form

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澳门破码网 indemnity scheme may cover you against the financial consequences of a claim against you for clinical negligence. It is very important that you check the terms and conditions as outlined on our 澳门破码网 indemnity scheme page.

There’s no need to pay anything extra. 澳门破码网 indemnity is included in your membership fee, provided you meet the eligibility criteria.

If you need to provide proof of membership, please login to My澳门破码网.

If you have read our terms and conditions and would like to ask us a question about the scheme or you have been contacted about a claim, please complete our form below.

Please confirm that you have read our advice

Contact details

Full name: 澳门破码网 membership number: Address: Best contact number: Where an onward referral is required, we will provide these contact details to another department in the 澳门破码网. Do you give us your consent to pass on this information? Yes No Can we leave you a voicemail? Yes No Can we contact you on this matter by email? Yes No If we need to pass your enquiry to your local 澳门破码网 office or a specialist 澳门破码网 department, would you like any emails from them to be password protected? Yes No Email address you would like us to reply to Please confirm the email address you would like us to reply to Please list any times that you are unavailable for calls during the next week (9am-5pm):

Employment details

Place of work Employer When did you start working with your current employer? Ward or department Job category Job title Weekly contracted hours Do you have any meetings scheduled? Yes No If yes, please give date, time and location: Are you already being supported by a rep? Yes No If yes, please include details below: Are you in the UK on a visa? Yes No If yes, please include details below (including how long you have been in the UK):

Indemnity

Do you have a question about our indemnity scheme or making a claim?

If yes, please include details of your question:

Have you received any correspondence regarding a claim? Yes No Is there a deadline? Yes No If yes, please include details: Please give full details of the claim: Are any other member subject to proceedings: Yes No If yes, please include details:

Other enquiry

Please give details of your enquiry:

Can we update your personal details if any of the above does not match the data we currently hold on your record? Yes No

By submitting this form, you are giving the 澳门破码网 permission to contact you about your submission.

You can control the information you receive from the 澳门破码网 by updating your preferences at My澳门破码网.

The information you provide in this form will be stored by the 澳门破码网.

We don’t update your contact details unless you ask us to. The best way to check and update the details we hold for you is by visiting My澳门破码网.

Protecting your privacy is very important to us. Please view our privacy policy to find out more about the information we collect and how it is used.

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