Registration Test Basic Information Speciality: —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 None Accident and Emergency Anaesthetics Bariatrics Cardiac Surgery Cardiology Cardiothoracic Surgery Child Psychiatry Dental Surgery Dental Vocational Training Dental Vocational Training 1st Year Dental Vocational Training 2nd Year Dental Vocational Training 3rd Year Dermatology Emergency Medicine Endocrine Surgery Endocrinology Eye / Optical Surgery Family Medicine Family Physican and Pub. Health Full Rate Dentist 4 Yr Up Gastroenterology General Practice General Surgery Geriatric GP(M1 Students) GP(M2 Students) GP(M3 Students) GP(M4 Students) Gynaecology Gynaecology/ Obstetrics Gynecological Surgery Hematology Hygienist Infectious Diseases Intensive Care Medicine Internal Medicine Maxillofacial Surgery Mid-Wives Neonatology Nephrology Neurology Neurosurgery No Speciality Nurse Practictioner Obstetrics Oncology Ophthalmology Oral and Maxillofacial Surgery Orthopedic Surgery Orthopedics Otorhinolaringology Pathology Pediatrics Pharmacist Plastic / Reconstructive Surgery Practice Nurse Proctology Psychiatry Psychology Pub. Health/Derm/G.P Pulmonary & Internal Med Radiology Registered Nurse Rehabilitation Medicine Rheumatology Sexual Health Sleep Medicine Sports Medicine/ No Surgery Sports Medicine/ WithSurgery Surgery Surgical Oncology Thoracic Surgery Toxicology Urology Vascular Surgery Application Type NewReinstatement Lapsed policy will attact 40% on basic premium First Name Middle Name Last Name Date of Birth: Email Address Next Address of Practice Mailing Address Sex MaleFemale Telephone Work Home Cell BackNext Practice Information Year Of Graduation Number of Years in Practice Name of Medical School Address of Medical School Internship Information Internship(1) Date Place Add More Internships Internship(2) Date Place Internship(3) Date Place Post Internship Information Internship(1) Date Place Duty Add More Post Internships Internship(2) Date Place Duty Internship(3) Date Place Duty Registration Information Kindly state your Governing Body Eg. Medical Council of Jamaica, Nursing Council of Jamaica etc. Registration Number Expiry Date Sub Speciality Primary Hospital Affiliation BackNext Would you need to do any of the following Practice outside of Jamaica? YesNo Please specify: Have coverage outside Jamaica? YesNo Please specify: Do you do any of the following: Laser surgery? YesNo Please specify: Laproscopic surgery? YesNo Please specify: Liposuction? YesNo Please specify: Transplant surgery? YesNo Please specify: Order or perform Blood Transfusions? YesNo Please specify: Any form of experimental surgery? YesNo Please specify: New drug trials? YesNo Please specify: Do you now carry Professional Indemnity Coverage? YesNo Please specify: Expiry Date Policy # Have you ever been declined Professional Indemnity Coverage? YesNo Please specify: Have you ever had your Professional Indemnity policy cancelled, refused at Renewal or had special terms imposed? YesNo Please specify: Have you ever had a medical negligence suit against you? YesNo Please specify: Do you have any medical negligence suits pending against you? YesNo Please specify: Are you aware of any circumstances that may result in medical negligence claim being made against you? YesNo Please specify: Do you supervise Ancillary Technical Personnel? YesNo Please specify: BackNext Rate Calculation Indicate the amount of coverage required: Select Level 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) Basic Premium Do you practice overseas? If yes please select the country: Please Select Barbados Trinidad & Tobago Cayman Islands Overseas coverage adds 25% to your premium. Do you practice any of the following? Please Select Laser Surgery Laproscopic Surgery Health Tourism 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? New policy Renewal / Reinstatement Is your policy lapsed? Yes No A lapsed policy adds 40% to your basic premium. Payment type Pay Full 2 Installments 3 Installments 4 Installments Total Premium First Installment Additional Installments BackNext Additional 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. I agree Back
