MPS Registration Form

1. As part of our normal process, we may approach your previous indemnity or insurance organisation for your claims history. This process will take a minimum of 15 working days.

2. Failure to disclose full and accurate details about your previous history,  practice and income may invalidate your membership which means you are not entitled to seek advice or assistance from MPS.

3. When completing the previous history section on pages 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. We will not assist with any matter arising from an incident pre-dating your MPS membership.

5. If you are leaving a claim made insurance contract, please ensure you have notified your previous provider of any adverse incident 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 MPS membership.

Please note that signing the declaration on page 7 indicates acceptance of the following requirements:
Members must keep MPS informed of their current address and any changes in their professional circumstances. Failure to notify us of any change of address or scope of practice could result in the suspension and/or the withdrawal of the benefits of membership and/or the cancellation and/or the termination of your membership. Members should understand that MPS is not an insurance company. 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.

The Medical Protection Society Limited (MPS) is a company limited by guarantee registered in England with company number 36142 at Level 19, The Shard, 32 London Bridge Street, London, SE1 9SG. MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association. MPS® and Medical Protection® are registered trademarks.

In this section, you must include details of any matter in which you have been named or involved. Please include any pending, unresolved or closed issues, even those already reported to MPS. If necessary please continue your answers on the enclosed pages. Please note that failure to disclose full and accurate details about your previous history may delay your application and/or if you are accepted into membership could result in the suspension and/or withdrawal of membership benefits and/or the cancellation and/or termination of membership.

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 Kingdom’s Data Protection Act 1998 (the Act)) which you provide to us or which we fairly obtain from another source for the purposes of processing your membership renewal, 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 renewal 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 from other professional defence organisations, insurance companies, employers or other third parties regarding your professional practice and career history 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 for any of the purposes for which you have agreed to allow us or them to hold or process your personal data.

IMPORTANT! – Please read, sign and add the current date below.
By signing and returning this form you confirm that:
(i) You wish to apply for membership of MPS subject to the Memorandum and Articles of Association
(ii) You understand that any failure to disclose full and accurate details may delay your application and/or if you are accepted into membership could result in the suspension or withdrawal of membership benefits and/or the cancellation and/or termination of membership
(iii) You understand that membership is not conferred automatically and is subject to approval by MPS
(iv) You acknowledge that any subscription payments made are subject to verification and that acceptance of a payment by MPS and/or the association does not of itself confirm membership and/or entitlement to request benefits
(v) You will inform us if your personal circumstances or scope of practice changes