Application – SIC Consultancy Services

Medical Malpractice Takaful

Application Form

Hint : This will take approximately 10-15 minutes of your time

Please read our Privacy Policy *

I have read Privacy Policy of https://sicconsultancyservices.com/

Instructions to the Applicant

This form is intended for individual healthcare practitioners. These include, but are not limited to, physicians, surgeons, dentists, pharmacists, physician assistants, nurses and other allied health and therapeutic care practitioners.
You must answer all the questions where neccessary.
If you are a new practice, use the projected figures from your business plan.
At the end of this form, you are required to upload images of your Identity Card, and Current Year APC in JPEG/GIF/PNG format
If you have any questions concerning this proposal, please contact us.

Choose your category *

Period of Takaful

Choose the date of coverage start and end

Date Coverage Start *

Date Coverage End *

Application for Takaful Cover

Application Form

Hint : This will take approximately 10-15 minutes of your time

Limit of Liability *

Limit of Liability (optional)

Choose your desired limit of certificate coverage.

Limit of Liability (optional)

Choose your desired limit of certificate coverage.

Excess/Deductable (Optional)

Deductible is where you request to pay some amount on each claim event. This is optional.

Excess/Deductable (Optional)

Deductible is where you request to pay some amount on each claim event. This is optional.

Retroactive Date (Optional)

Are you requesting cover for Cyber and Privacy Infringement Liability? (Optional)

Yes

Details of Applicant

Full Name *

Name of applicant

IC Number *

Gender *

Male

Female

Primary practice address *

Correspondence address *

Are you duly licensed to practice at the address(es) specified? *

Yes

Contact phone number *

Email address *

Please indicate your qualification(s):

Name of Institution *

Highest

Degree of Qualification (Optional)

Second highest qualification

Year Obtained (Optional)

Second highest qualification

Name of Institution (Optional)

Degree of Qualification (Optional)

Year Obtained (Optional)

Details of Registration

Licensing / Registration Body : *

MMC

Registration Number : *

Registration Date : *

Date of first Registration :

Other registration details (optional)

Please list any medical societies & associations you are a member of : (optional)

Have you ever had any of the organisations declared in previous questions refused, suspended, withdrawn or had conditions imposed at any time? *

Yes

If YES, please provide details on a separate sheet, noting the Section number.

DETAILS OF HEALTHCARE SERVICES / BUSINESS

Please indicate in (%) your classification and volume of work according to your field of service

For Doctors

Anaesthesiology (%)

General Practitioner (%)

Cardiology (%)

Ophthalmology - including LASIK & laser (%)

Dermatology (%)

Paediatrics - no surgery (%)

Dentist – Cosmetic Dentistry (%)

Psychiatry (%)

Dentist - Employer Indemnified (%)

Radiology (%)

Dentist – Endodontist / Periodontist / Prosthodontist (%)

Dentist – General Dentistry (%)

Gastroenterology (%)

Others (%)

Total percentage must be 100%

You may skip to Income and Patient Numbers

For Surgeon

Bariatric Surgery (%)

Oncology (%)

Cardiothoracic Surgery (%)

Oral Maxillofacial Surgery (%)

Ear/Nose/Throat (%))

Orthopaedic Surgery (%)

General Surgery (%)

Paediatric Surgery (%)

Gynaecology (%)

Plastic Surgery - elective / cosmetic (%)

Hand Surgery (%)

Plastic Surgery - reconstructive (%)

Neurosurgery (%)

Obstetrics/maternity (%)

Others (%)

Total percentage must be 100%

You may skip to Income and Patient Numbers

For Allied Health & Ancillary Staff

Counsellor (%)

Chinese Medicine Practitioner (%)

Chiropractor (%)

Dental Assistants - Therapist, Hygienist, Technician (%)

Diagnostic Radiographer (%)

Healthcare Assistant/Worker (%)

Massage Therapist (%)

Midwife (%)

Nurse (%)

Occupational Therapist (%)

Optometrist (%)

Osteopath (%)

Pharmacist (%)

Physiotherapist (%)

Total percentage must be 100%

You may skip to Income and Patient Numbers

Podiatrist (%)

Psychologist (%)

Therapist Aide (%)

Others (%)

Total percentage must be 100%

You may skip to Income and Patient Numbers