Medical Auxiliary Insurance Brokers (MAIB)

Enquiry Form

A * indicates a required entry.
First name:*	Phone:*
Surname:*	Email:*
Address:*
City / Town:*
County:
Post code:*
Country:

Therapies / treatments to be covered:*	Qualifications:* Indicate qualifying bodies (e.g. ITEC, IIHHT, VTCT or college details) and when qualified


Have you practised continuously since qualification?*		Yes No
If not, please explain how you have maintained your practical competence, e.g. treating family and friends.


Limit of indemnity for Public/Products/Malpractice Liability:		£
If you have chosen 'other', please state the limit of indemnity you need:		£
Do you require additional product liability for goods/products supplied, not as part of a course of treatment?* The policy will automatically indemnify you for liability arising from products sold to your customers as part of a course of treatment. Will you sell products to anyone other than as a course of treatment?		Yes No
Personal Fitness Trainers:* Do you get involved in personal fitness work? If so, an additional enquiry form will be sent to you.		Yes No

Is cover required in respect of:
Tuition cover* Do you teach others to become practitioners?		Yes No
Student cover* For supervised work prior to qualification		Yes No
EU work*		Yes No
Workshop cover* Do you do any workshops / exhibitions / demonstrations / group work?		Yes No
All risks cover* Do you require cover for your business equipment, including stock?
If you have chosen 'another limit', please state the limit of indemnity you need, the minimum being £1,000.00:		£
Do you require Employer's Liability Insurance?* this is a statutory requirement, if you employ anybody in the business on a full-time, part-time or temporary basis		Yes No

Have any claims ever been made against you in respect of the risk to which this proposal relates, or have you had any convictions against you which could affect this enquiry?*		Yes No

Have you held any previous insurance?*		Yes No
If yes, with whom?