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GMC Or GDC Registration: GMC GDC
GMC/GDC Registration No:
Year of above registration (YYYY):
Year of qualification (YYYY):
Professional Qualification:
Please provide following details as they appear in GMC or GDC record
Title:  
First Name:
Middle Name:
Last Name:
Date of Birth:

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County:
Postal Code:
Address on which you would like to be contacted if different from above
Address Line 1:
Address Line 2:
City:
County:
Postal Code:
Contact Details
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Telephone (Evening):
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E-mail:
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Job Titles with Grade
Description of Current Role:    
Are you employed or self employed?:  
Declaration of Pre-existing issues
We do not provide cover for issues that have existed before commencement of membership. Please make a full declaration of existing or previous issues:
1. Please provide details of any concerns raised about your conduct, capability or health in the past five (5) years. This should include any formal and/or disciplinary investigation by your employer or those who hold your performer’s list registration.:
2.Are you aware of any matters that may result in or have resulted in a claim or complaint being made against you? Please provide full details. Not disclosing information that we consider relevant may invalidate your membership. Therefore if you are unsure if certain information you have would qualify to be stated then please do state that here:
3. Have you been subject to any Employer’s disciplinary investigation, inquiry or other proceedings, GMC/GDC investigation, inquiry or other proceedings, Coroners’ Inquest or Fatal Accident Inquiry and/or criminal prosecution in the past ten (10) years?:
Claims Information
1.Have any claims or complaints relating to your professional work been made or threatened against you in the past three (3) years? If so, please provide details :
2.Are you aware of any acts, errors, omissions, incidents, events or circumstances which may give rise to a claim, investigation or complaint against you? If so, please provide details:
3.Have you ever had membership or cover cancelled, declined or refused to be renewed by a professional membership organisation or provider of professional indemnity? If so please provide details.:
4. Please provide details of the following in respect of any policy or membership that you have or which is expiring at the time of joining our membership:
a) Name of the membership or defence organisation.

b) Expiration date of membership/policy.

Declaration in respect of indemnity for “Good Samaritan Acts” and “Category 2 work” (Fee Paying work):
DDPU provides indemnity for Good Samaritan Acts for all its members. For members working in the NHS Hospitals, DDPU also provides indemnity for Category 2 work (Fee Paying Work). This is work which is linked to your NHS work but for which you are paid an additional fee (for details, please see paragraph 37, Terms and Conditions of Service NHS Medical and Dental Staff).

Please provide the following information :-

1. Have you ever had a claim (whether insured or not ) in respect of Good Samaritan Acts or Category 2 Work (Fee Paying Work)? If yes, please give details.  
2. Do you work in NHS Hospitals? If yes, please give details.