Society Of Radiographers Insurance Application

  1. 1. Please advise personal information as follows:
  2. 2. (a) Please advise details of Your Health & Care Professions Council registration as follows:
  3. (b)
  4. Yes  No
  5. 3. (a) Please advise your membership number of the Society of Radiographers:
  6. Yes  No
  7. (b)
  8. Yes  No
  9. 4. (a) Please advise whether you contract using a legal Entity name (e.g. a registered Limited company) rather than in your own personal capacity, for fiscal purposes?*
  10. Yes  No
  11. Yes  No
  12. (b)
  13. Client Name Type of client (e.g. NHS Trust, Private Clinic, Private Hospital, Other Private Services Provider) Proportion of Annual Revenue Earned Average Working Hours For This Client Per Week
    % Hours
    % Hours
    % Hours
  14. Yes  No
  15. 5. Please advise your gross revenue (before deductions) earned as deatiled below. This should exclude work where you have a PAYE Employment contract with a corporate entity such as a NHS body or Private Limited Company (not considered under this insurance):*
  16. Estimate of current Financial Year Last Full Financial Year
    Private Work £ £
    Work for any NHS body or trust £ £
    Gross Revenue £ £
  17. 6. (a) Please advise what proportion (estimated %) of revenue earned in the last 12 month relates to the following:
  18. %
  19. %
  20. %
  21. %
  22. %
  23. %
  24. %
  25. (b)
  26. Yes  No
  27. 7. Have you ever had practice related issues in connection with drug and/or alcohol abuse, sexual addiction or mental illness?*
  28. Yes  No
  29. 8. Have you ever been diagnosed with, or treated for, a chronic physical or mental illness and/or disability?*
  30. Yes  No
  31. 9. Claims History
  32. This insurance is underwritten on a 'claims made' basis and Underwriters will exclude any claim and/or circumstance which could reasonably be expected to give rise to a claim, which is known by YOU prior to the inception date of the policy.

    Please provide answers to the following questions

  33. Yes  No
  34. Yes  No
  35. Yes  No
  36. Yes  No
  37. Yes  No
  38. Yes  No
  39. Yes  No
  40. Yes  No
  41. Yes  No
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