Application for Dental Membership of the Medical Protection Society - UK Dentists and Oral & Maxillofacial Surgeons

Please complete in block capitals all sections of the form and return to Membership Operations, Medical Protection Society, Victoria House, 2 Victoria Place, Leeds LS11 5AE, UK. If your admission into membership of MPS is approved, it will be dated from the day following receipt of your application. Complete this box if you would prefer membership to commence on a later date: This form should not be submitted earlier than 8 weeks before your required start date.

Personal details
Title Forename UK address for correspondence

Surname Postcode E-mail Date of birth . Sex . Mobile no Degrees and Diplomas Country of practice Dental School Month and year of graduation in or outside of the UK GDC registration no. M F Telephone (Daytime) (Evening)

Former name (if any)

Will all your dental practice be carried out in the UK? Will any of your dental practice be carried out in Scotland?

Yes Yes

No If no, please give full details on additional pages provided No Yes No

If yes will more than 50% of your clinical practice be carried out in Scotland. If you are registered to practise in any other countries please state which:

Important Information
1. As part of our normal process, we may approach your previous indemnity or insurance organisation for your claims history. This process may take a minimum of 15 working days. 2. Failure to disclose full and accurate details about your previous history, practice or relevant income may invalidate your membership which means you are not entitled to any advice, assistance or other benefits of membership. 3. When completing the previous history section on page 2 and 3 you must account for any gaps in your indemnity or insurance history during the last 10 years and also any break in clinical practice during the previous 2 years. 4. If you have had professional indemnity or insurance for any practice outside of the UK (other than from MPS) you must obtain your case history to submit with this application. 5. We will not assist with any matter arising from an incident pre-dating your membership. 6. If you are leaving an insurance contract, please ensure you have notified your previous provider of any adverse incidents of which you are aware, that could become a claim. You should also check with the provider whether any closing payment is required to secure run off cover for any future claim which may arise from an incident pre-dating your membership. 7. It is your responsibility to provide accurate information about your professional practice and relevant income (which may affect the subscription you pay). Failure to notify us of any changes of address, income and/or sessions could result in the suspension of the benefits of membership and/or the termination of your membership. Members should understand that neither MPS nor DPL are insurance companies. 8. The benefits of MPS membership are granted at the discretion of Council and are subject to the terms and conditions of the MPS Memorandum and Articles of Association, as amended from time to time. Dental members are serviced by Dental Protection.

MPS Office use only

Date form sent: Date received: Approved by: Date approved: Processed: Start date: Joining reason: _____________________________________ Grade: _____________________________________ Status: _____________________________________ Specialty: _____________________________________ DP: _____________________________________ Access number: _____________________________________ Membership number: _____________________________________ Notes:

DPLUKFEB14

In this section you must include details of any matter where you have been named or involved. Please include any pending, unresolved or concluded issues, even those already reported to DPL or MPS. Failure to disclose details about your previous history may invalidate your membership.

Previous Indemnity/Insurance
1. Have you had any professional indemnity/insurance before? YES (Please go to Q2) NO (Please go to Q4)

2.

Please give the name of all other organisations and the dates during which you were a member or policyholder. If you were previously a member of DPL, please give your membership number and your name at the time (if it has changed). Organisation From To DPL No. Name Other membership (DD/MM/YYYY) (DD/MM/YYYY) or policy number

3.

Have there been any gaps in your professional indemnity (excluding NHS indemnity) during the last ten years? (If in doubt please indicate YES.) If you have answered YES please confirm the dates and the reason for any gap below.

YES NO

4.

Have there been any breaks in your clinical practice in the last 2 years? (If in doubt please indicate YES.) If you have answered YES please confirm the dates and the reason for any gap. Please also provide details of any continuous professional development or refresher training that has been undertaken.

YES NO

5.

Have you ever been refused professional indemnity/insurance, including refusal to renew or been offered limited or conditional terms or a higher/enhanced subscription/premium? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words providing dates and reasons, including copies of any correspondence.

YES NO

6.

In the last 10 years have you been the subject of any complaint arising out of your professional practice? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words of the events leading to the complaint(s) including dates, the extent of your involvement and also the final outcome.

YES NO

If you have answered YES to any of the above questions please provide details as requested. Use the additional pages provided if needed. Failure to disclose full and accurate details about your previous history may delay your application.

7.

Have you ever been involved in any claim for compensation arising out of your professional practice or are you aware of any incident that might become a claim? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words of the events leading to the claim(s) declared, including dates, the extent of your involvement and also the final outcome.

YES NO

8.

Have you ever been the subject of a disciplinary inquiry by your employer or had practice privileges refused/withdrawn/made conditional by a private health care provider? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words to include dates, the extent of your involvement and also the final outcome. Copies of any associated correspondence must be provided.

YES NO

9.

Have you ever been subject to any referral, complaint, inquiry or investigation or hearing by the GDC or any other registration body or had conditions imposed on your practice or been suspended or erased from a dental register? (If in doubt please indicate YES.) If you have answered YES please provide a summary in your own words of the events leading to the registration body inquiry/investigation, including dates, the extent of your involvement and you must provide copies of any final determination letter(s).

YES NO

10.

Have you ever been cautioned by the police in respect of, or convicted of, any criminal allegation (including road traffic offences)? If you have answered YES please provide a summary in your own words to include the nature of the offence, the final outcome or the current position and whether the offence was reported to any registration body.

YES NO

11.

Are there any other issues of which we might reasonably need to be aware when considering your application for membership? (If in doubt please indicate YES.) If you have answered YES please provide all relevant information below.

YES NO

If you have answered YES to any of the above questions please provide details as requested. Use the additional pages provided if needed. Failure to disclose full and accurate details about your previous history may delay your application.

Section A - General and/or Specialist Practice

If you are undertaking practice in both general and/or specialist practice and within an employer indemnified post, please ensure that sections A & C are both complete. A1. Please tick the box/es below which best describes your position:
Vocational Training/Foundation Training General Professional Training Year 1 General Professional/Foundation Training Year 2 Vocational Training/Foundation Trainer (General Dental Practitioner) General Dental Practitioner who has previously completed vocational training/GPT in the UK or Ireland General Dental Practitioner who has not previously completed vocational training/GPT in the UK or Ireland Oral (dento-alveolar) surgery exceeding 10 hours/week on average Other (state)_________________________________________

A2. Specialist Practice, please specify specialty e.g orthodontics

Are you on a specialist register? YES NO If yes, please state which one(s):_______________________________________

(if oral and maxillofacial surgeon, complete section E) If you are claiming a concessionary rate, complete sections F and G as appropriate.

A3. Are you:

A practice owner Working in a practice owned by other(s) Are you applying for membership as part of a DPL Xtra practice? Employed Self Employed YES NO

If yes please provide the DPL Xtra practice number and then go to section B. If no please go to section A4. DPL Xtra number

A4. Do you have any other responsibilities as a practice principal? Do you employ dental nurses or dental technicians?
If yes, how many dental nurses/dental technicians do you employ? YES

YES NO

NO

Would you like these nurses/dental technicians to be indemnified against negligence claims only NO in this way? If YES, please provide details in Section H. YES

Section B Members employed in the Keep In Touch Scheme (KITS) - no clinical activity
Members in this category are able to receive free publications and other discounted risk management resources

B1. If you participate in the KITS Scheme, please tick this box.

Section C Employer Indemnified

Those with indemnity provided by their employer or NHS Indemnity/Crown Indemnity including those who have involvement in dentistry outside of their employer indemnified appointment (e.g. private practice).
C1. Please indicate your main area of practice from the list below:
Please state your current position within your area of practice e.g SHO, Senior Dental Officer etc University/Dental School Staff Community Service HM Armed Forces Dental Reference Officer Hospital Dental Public Health HM Prisons Other, please specify Speciality:

Are you on a specialist register?

YES NO

If yes, please state which one(s):

C2. Do you carry out any private work or have any involvement in dentistry outside your employer indemnified appointment?
NO YES, please specify Up to & including 5 hrs/wk (250 hrs/yr) Up to & including 20 hrs/wk (1000 hrs/yr) Up to & including 10 hrs/wk (500 hrs/yr) More than 20 hrs/wk (1000 hrs/yr)

and indicate the extent of your involvement in dentistry outside your employer indemnified appointment

I undertake to notify MPS promptly if my circumstances change and understand that if I fail to do so, my rights to seek assistance may be lost.

Section D Cosmetic and/or Oral (dento-alveolar) Surgical Procedures

D1. Do you carry out any of the following?
Oral (dento-alveolar) surgery YES NO Defined cosmetic procedures YES NO

D2. What percentage of your time in private practice do you spend carrying out oral (dento-alveolar) surgery or defined cosmetic procedures (excluding the neck) collectively on average per week?
Less than 25% More than 25%

D3. If you carry out defined cosmetic procedures are you registered with CHKS/IHAS and hold the IHAS Quality Mark standard?
YES NO If you answered No to D3., please include a separate written statement on the additional page provided, detailing the extent of your involvement, and provide copies of your certificate(s) of training.

Section E Oral and Maxillofacial Surgery

E1. Do you undertake any oral or maxillofacial procedures in private practice?
NO YES

Group 1 procedures - how many hours per week? Group 2 procedures - how many hours per week? Are you on a Specialist Register? If yes, please state which one(s): NO YES Speciality:

Concessionary Rates Section F Non-Clinical Practice

F1. If you have no direct contact with any patients, please tick one of the boxes below:
I have no clinical commitment and have up to & including 3 hours/week (less than 150 hours per subscription year) total involvement in dentistry and no responsibilities as a practice principal. I have no clinical commitment and have up to & including 10 hours/week (less than 500 hours per subscription year) total involvement in dentistry and no responsibilities as a practice principal. I have no clinical commitment but have more than 10 hours/week (more than 500 hours per subscription year) total involvement in dentistry, including any responsibilities as a practice principal.

F2. Please describe your position:

Section G Limited Clinical Activity

G1. If you wish to apply for a reduced subscription rate because your clinical activity is limited, please tick one of the boxes below.
Up to & including 3 hours/week (150 hours/year) Up to & including 10 hours/week (500 hours/year) Up to & including 15 hours/week (750 hours/year) Up to & including 20 hours/week (1,000 hours/year) Up to & including 25 hours/week (1,250 hours/year) I undertake to notify MPS promptly if my circumstanc es c hange and understand that if I fail to do so, my rights to seek assistanc e may be lost.

G2. Please describe your position:

Section H Employed Dental Nurses and Dental Technicians

We need the full name of each dental nurse/dental technician that you employ and for whom you wish to have the right to request indemnity against clinical negligence claims only through your own membership at no extra cost. Please underline the surname/family name.

Name 1. 2. 3. 4. 5. Please note: Assistance may be requested for claims against the above named nurses/technicians through your practice principal membership for clinical negligence only. With the number of complaints and GDC investigations involving dental nurses and dental technicians on the rise and the fact that 80% of all our cases are not related to clinical negligence we recommend that dental nurses and dental technicians have full individual membership. The above named nurses/technicians can apply for full dental membership at a 50% discount, in order to provide them with personal indemnity in relation to professional matters other than negligence claims (for example, GDC complaints or investigations, inquests, criminal allegations etc). Alternatively they can be fully indemnified for free through the DPL Xtra practice programme. For more information regarding membership for dental nurses/dental technicians or the DPL Xtra programme go to www.dentalprotection.org or contact the Service Centre helpline on 0845 718 7187.

Please ensure that you keep us informed of the names of any nurses/technicians who start or leave your employment, take maternity leave or other career breaks etc.

Declaration
You must sign and return this form with a current date. Any delay in returning this form may invalidate this application. I wish to apply for dental membership of MPS subject to the Memorandum and Article of Association and upon payment of the appropriate subscription. I confirm that I have read the important information on the guidance sheet. I understand that membership is not conferred automatically and is subject to approval. I confirm that the information I have provided is correct to the best of my knowledge and belief. I confirm that I have completed and enclosed the payment instruction form. Payments made are subject to verification and acceptance of a payment by MPS does not of itself confirm membership and/or entitlement to request benefits.

Important - Your data

At times we will ask you to provide us with data and personal information including when you apply for membership, your subscription is renewed, your scope of practice changes and if you seek and we provide assistance to you. In applying for membership and by continuing as a member you agree that (i) we may hold and process your personal data including sensitive personal data (as defined in the United Kingdoms Data Protection Act 1988 (the Act) which you provide to us or which we fairly obtain from another source for the purposes of processing any application for membership, the administration and provision of membership services, providing you with the benefits of membership (including, but not limited to, advice, assistance and indemnity), underwriting, risk assessment, marketing, education, research and audit during your membership and for a reasonable period after your membership terminates or an application for membership is rejected by us or withdrawn by you and (ii) we may share such data with third parties who may also hold and process the data for the same purposes. Under the Act you have the right to ask us for a copy of any of your personal data which we hold, for which we make a nominal charge. You also agree that (i) we may seek information relevant to any purpose for which you have agreed we may hold personal data regarding past and current matters from other professional defence organisations, insurance companies or employers with whom you have had professional indemnity arrangements or been employed and that they may release to us such information (ii) if you are outside of the European Economic Area (EEA) your data may be transferred to, held and processed within the EEA and (iii) if you provide us with an email address or telephone number it may be used by us and third parties to contact you any of the purposes for which you have agreed to allow us or them to hold or process your personnel data. If you are submitting additional sheets or correspondence, please tick here In order to provide you with the best possible service we would like to inform you of other products and services offered by us that we believe may be of interest to you. If you do not wish to receive such information, either via post or email, please tick here

Signature

Date (DD/MM/YYYY)

Where did you learn about Dental Protection?

At dental school Personal recommendation Mailing from Dental Protection Other, please specify Press advertising GDC A Lecture/Presentation

If you choose to pay by Direct Debit in instalments, your MPS membership subscription payments will become due and payable on each of the Direct Debit payment dates as notified to you by MPS. The first subscription payment covers your MPS membership between the membership start date and the date of that subscription payment. Each following subscription payment covers your MPS membership between the date of that subscription payment and the previous subscription payment which became due and payable, and if it is the final subscription payment in a subscription period (again as notified by MPS to you) it also covers the period from the date of the subscription payment to the expiry of the subscription period. If you fail to pay all or any part of your subscription for any period of membership we may suspend or terminate your membership and/or allocate any payments received by us in the manner set out in section 7(a) of the MPS Memorandum and Articles of Association. However, we do not consider failed payments as creating a debt to us since MPS membership is discretionary and, accordingly, we will not take legal action against you for your failure to pay.

Payment details - Direct Debit instruction Please do not remove.

Payment instruction UK
0845 718 7187 member.help@mps.org.uk .help@m

Please COMPLETE and RETURN with your application for membership

To T oa apply for membership ect Memorandum Articles pply f or dental m embership of MPS subj e ct to the terms terms and conditions conditions of the MPS Me morandum and Art icles of Association please ensure you have completed all relevant sections pl ease e nsure y ou h ave co mpleted a ll r elevant s ections of of the the form. form. Please your preferred payment from return P lease choose choose y our p referred p ayment method f rom the list below and r eturn this instruction with your application form and any enclosures enclosures to: to: Membership Membership Operations, Dental Dental Protection Protection Limited, Limited, Victoria Victoria House, 2 Victoria Victoria Place, Place, Leeds Leeds LS11 LS11 5AE, UK UK in the pre-paid pre-paid envelope provided. provided.

How to pay your subscription

P Please lease n note: ote: N No o pa payment yment w will ill b be ep processed rocessed unt until il your your ap application plication has been app approved. roved.
Pa Payment yment metho methods ds ( (please please tick tick one one box box below) below)
Payment Payment b by y deb debit/credit it/credit ca card rd i in nf full ull. D Delta/Visa/Maestro/Mastercard elta/Visa a/Maestro/Mastercard payers payers o only. nly. (MPS (MPS does does not not accept accept American American Express). Express). Y You ou w will ill be s sent ent a an ni invoice nvoice o once nce y your our applicatio application n fo for r me membership mbership ha has s bee been n app approved. roved. Payment Pa yment b by Direct Debit annual. yD irect De bit annual . To pay your subscription single Direct Debit payment please complete instruction below. T op ay y our subscr iption iin nas ingle D irect D ebit pa yment pl ease c omplete the instru ction belo w. See important information about Direct Debit payments overleaf. Payment b Payment by Direct Debit instalments no cost). yD irect De bit insta lments (at n o extra cost) . T To op pay your subscription by monthly Direct Debit (for subscriptions over 100) complete below. our subscr iption b ym onthly D irect D ebit (f or subs criptions ov er 100) please c omplete the instruction belo w. ay y See important information about Direct Debit payments overleaf. Payment b Payment by cheque in full y che que i n fu ll. C heques shou Cheques should be enclosed when returning Society Limited. Limited. ld b ee nclosed w hen r eturning the form. form. They They should should be be crossed crossed and made made payable payable to the the Medical Medical Protection Protection Society

Please ll in the whole form using a ball point pen and send to: Medical Protection Society, Granary Wharf House, Leeds, LS11 5PY, UK. Membership helpline 0845 718 7187.
Please ll in the whole form using a ball point pen and send to: Membership Operations, ons, , Dental Protection Limited, Victoria House, 2 Victoria Place, Leeds LS11 5AE, UK. Membership helpline 0845 718 7187. Name and postal address ofbank youror bank or building Name and fullfull postal addr ess of your building society society Bank/building society To: The Manager

Instruction to your bank or building society to pay by Direct Debit

Service user number

Service 4 user 3 number 4 Reference number Reference Member name

Address FOR MPS OFFICIAL USE ONLY

Postcode
Name(s) of account holder(s)

Postcode

Name(s) of account holder(s)

This MPS is not direct part of debits the instruction to your bank detailed or building Please pay from the account insociet this y. instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with MPS and, if so, details will be passed electronically to my bank/building society. Instruction to your bank or building society Please pay MPS Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with MPS and, if so, details will be passed electronically to my bank/building society. Signature(s) Signature

Bank/building society account number

Bank/building society account number Branch sort code Branch sort code

Date (DD/MM/YYYY)
Date

Banks and building societies may not accept Direct Debit Instructions for some types of account. Banks and building societies may not accept Direct Debit Instructions for some types of account.
MPS0184_UKDD_DPL: 02/11

Contacting us:
To discuss your application, renewal or subscription, please call the Service Centre helpline on: 0845 718 7187 (from UK - your call will be charged at local rates) or on +44 (0) 207 399 1400 (international) or write to us at: Membership Operations Dental Protection Limited Victoria House 2 Victoria Place Leeds LS11 5AE Email: member.help@mps.org.uk For dentolegal advice and assistance, please call the main switchboard on: 0845 608 4000 (from UK) or on +44 (0) 207 399 1400 (international) or write to us at: Dental Protection Limited 33 Cavendish Square London W1G 0PS Dental Protection Limited Victoria House 2 Victoria Place Leeds LS11 5AE Dental Protection Limited 39 George Street Edinburgh EH2 2HN Or contact us via our website at www.dentalprotection.org

Dental Protection Limited (registered in England No. 2374160) is a wholly owned subsidiary of The Medical Protection Society Limited (MPS) which is registered in England (No. 36142). Both companies have their registered office at 33 Cavendish Square, London W1G 0PS. Dental Protection Limited serves and supports the dental members of MPS, with access to the full range of benefits of membership which are all discretionary and set out in MPSs Memorandum and Articles of Association. MPS is not an insurance company.