Please fill out this registration form to apply for membership.
—Please choose an option—Accident and EmergencyAnaestheticsBariatricsCardiac SurgeryCardiologyCardiothoracic SurgeryChild PsychiatryDental SurgeryDental Vocational TrainingDental Vocational Training 1st YearDental Vocational Training 2nd YearDental Vocational Training 3rd YearDermatologyEmergency MedicineEndocrine SurgeryEndocrinologyEye / Optical SurgeryFamily MedicineFamily Physican and Pub. HealthFull Rate Dentist 4 Yr UpGastroenterologyGeneral PracticeGeneral SurgeryGeriatricGP(M1 Students)GP(M2 Students)GP(M3 Students)GP(M4 Students)GynaecologyGynaecology/ ObstetricsGynecological SurgeryHematologyHygienistInfectious DiseasesIntensive Care MedicineInternal MedicineMaxillofacial SurgeryMid-WivesNeonatologyNephrologyNeurologyNeurosurgeryNurse PractictionerObstetricsOncologyOphthalmologyOral and Maxillofacial SurgeryOrthopedic SurgeryOrthopedicsOtorhinolaringologyPathologyPediatricsPharmacistPlastic / Reconstructive SurgeryPractice NurseProctologyPsychiatryPsychologyPub. Health/Derm/G.PPulmonary & Internal MedRadiologyRegistered NurseRehabilitation MedicineRheumatologySexual HealthSleep MedicineSports Medicine/ No SurgerySports Medicine/ WithSurgerySurgerySurgical OncologyThoracic SurgeryToxicologyUrologyVascular Surgery
Do you have sub-specialties?
—Please choose an option—YesNo
Accident and Emergency
Dental Vocational Training
Dental Vocational Training 1st Year
Dental Vocational Training 2nd Year
Dental Vocational Training 3rd Year
Eye / Optical Surgery
Family Physican and Pub. Health
Full Rate Dentist 4 Yr Up
Intensive Care Medicine
Oral and Maxillofacial Surgery
Plastic / Reconstructive Surgery
Pulmonary & Internal Med
Sports Medicine/ No Surgery
Sports Medicine/ WithSurgery
Lapsed policy will attact 40% on basic premium
Date of Birth:
Address of Practice
Year Of Graduation
Number of Years in Practice
Name of Medical School
Address of Medical School
Add More Internships
Add More Post Internships
Kindly state your Governing Body Eg. Medical Council of Jamaica, Nursing Council of Jamaica etc.
Primary Hospital Affiliation
Practice outside of Jamaica?
Have coverage outside Jamaica?
Order or perform Blood Transfusions?
Any form of experimental surgery?
New drug trials?
Do you now carry Professional Indemnity Coverage?
Have you ever been declined Professional Indemnity Coverage?
Have you ever had your Professional Indemnity policy cancelled, refused at
Renewal or had special terms imposed?
Have you ever had a medical negligence suit against you?
Do you have any medical negligence suits pending against you?
Are you aware of any circumstances that may result in medical negligence claim being made against you?
Do you supervise Ancillary Technical Personnel?
Indicate the amount of coverage required:
Level 1 : $70.0 M
Level 2 : $35.0 M
Level 3 : $20 M
Level 4 : $10.0 M
Level 5 : $5.5 M
Group (based on specialty and sub-specialty chosen)
Do you practice overseas? If yes please select the country:
Trinidad & Tobago
Overseas coverage adds 25% to your premium.
Do you practice any of the following?
Laser surgery adds 15% to your premium.
Laproscopic surgery adds 20% to your premium.
Health tourism adds 100% to your premium.
Proposed commencement date of policy:
Is this a new policy or renewal?
Renewal / Reinstatement
Is your policy lapsed?
A lapsed policy adds 40% to your basic premium.
I HEREBY DECLARE: that the above statement and particulars are true and that I have not suppressed or misstated any material facts and I agree that this Proposal Form and any supplementary information sheet(s) attached hereto shall be the basis of the contract with the MAJIF TRUST.
19A Windsor Avenue
Office Phone: 876-946-1105-7