THIS APPLICATION IS ONLY FOR PODIATRIC SURGICAL STUDENTS - (You are defined as a Student
for insurance purposes until you are in possession of a Certificate of Completion of Podiatric
Surgical Training (CCPST))
Please carefully read the following information before proceeding with your application.
1. Disclosure
You must provide complete and accurate answers to the questions we ask you when you purchase a
policy for the first time, make changes to your policy, or renew your policy.
Insurance is based on the information that you give to the insurer and if this information is wrong or
incomplete, there may be adverse consequences as per the Insurance Act 2015: claims may not be
paid in full or at all, your policy may have special terms imposed or be cancelled, your policy may be
voided, and the premium paid may not be returned. If you are in doubt, please seek independent
advice or contact us for clarification.
You must provide us with a “fair presentation” of the risk. This is one:
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which discloses every “material circumstance” which you know, or ought to know, or which
puts the insurers on notice that it needs to make further enquiries for the purpose of
revealing those material circumstances, and
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in which every material representation as to a matter of fact is substantially correct, and
every material representation as to a matter of expectation or belief is made in good faith.
A “material circumstance” is one which would influence the judgment of a “prudent insurer” in fixing
the premium or determining whether to cover the risk.
You must make this disclosure in a manner which would be reasonably clear and accessible to a
“prudent insurer”.
Additionally, once the policy has come into effect, the policy itself contains specific terms requiring
you to notify us in a timely fashion regarding incidents and circumstances that are reasonably likely
to result in a claim being made against you. Please ensure that you read your policy carefully and
that you understand your obligations in this regard.
This application form must be completed by the proposed individual. All questions must be
answered. If there is insufficient space to provide answers, additional information should be
provided on the proposers’ letter-headed paper.
2. Formalities
Premium Medical Protection is an appointed representative of Harley Street Insurance Group Limited,
which is authorised and regulated by the Financial Conduct Authority (FRN: 570717).
Registered in England and Wales, Company Registration Number:
07098260. Registered Office: 25 Athena Court, Athena Drive, Tachbrook Park, Warwick, England, CV34 6RT.
Insurance is underwritten by Berkshire Hathaway International Insurance Limited,
trading as MedPro, which is authorised and regulated by the Prudential Regulation Authority
and regulated by the Financial Conduct Authority FRN 202967.
3. Your Data
We will only use your information insofar as it is necessary to administer your insurance contract or
in connection with a claim. Please see our Privacy Notice for more information on how we handle
your data.
