טופס Insurance Application Legal Liability Insurance for Clinical Trials – ביטוח כללי להורדה, הדפסה ומילוי מקוון

לפניכם כל המידע שתחפשו על טופס Insurance Application Legal Liability Insurance for Clinical Trials - ביטוח כללי. כאן תוכלו למצוא קובץ PDF של הטופס, מקורות מידע, חלופה נגישה לטופס, מילוי טופס מקוון אונליין, ומידע על הגשת הטופס באינטרנט.

טופס Insurance Application Legal Liability Insurance for Clinical Trials – ביטוח כללי להדפסה

מה זה טופס Insurance Application Legal Liability Insurance for Clinical Trials - ביטוח כללי?

Form Name: Phoenix Legal Liability Insurance for Clinical Trials Application Form

Summary: This is an application form for legal liability insurance for clinical trials provided by The Phoenix Pension and Provident Insurance company. The form collects information about the applicant, the clinical trial, and the insurance requirements.

Sections and Information Required:

1. Named Insured: The applicant's name, ID number, address, telephone, and email.
2. Description of Business: A brief description of the applicant's business.
3. Date Business was established: The establishment date of the applicant's business.
4. Other parties to be covered by the Policy: Details of any other parties to be covered by the insurance policy.
5. Hospital(s) and/or Institution(s) where the trials are to be performed: Names of hospitals or institutions where the clinical trials will take place.
6. Title(s) of the Trial(s) for which insurance is sought: Trial titles and phases (I, II, III, or other).
7. No. of Trial Subjects: The number of subjects participating in the trial.
8. Minimal age of Trial Subjects: The minimum age of trial subjects.
9. Status of Helsinki Committee approvals: Details about approvals from Helsinki Committees, including approval dates.
10. Date the Trial is to begin: Start date of the clinical trial.
11. Date the Trial is to end: End date of the clinical trial.
12. Time of Trial per participant: Duration of the trial for each participant.
13. Compliance with Regulations: Information about compliance with regulations, including public health regulations, Helsinki Committee approvals, Ministry of Health guidelines, Good Clinical Practice, and Consent Forms.
14. Product Liability Insurance: Whether product liability insurance is in force for medications, pharmaceuticals, or medical devices involved in the trial.
15. Location of Trials: Whether all trials are conducted in Israel or in other countries.
16. Requested Limits of Liability: Desired limits of liability.
17. Incidents in the Last 5 Years: Details of any incidents in the last 5 years involving death, injury, disease, or illness related to clinical trials.
18. Summary of Similar Trials in the Last 12 Months: Summary of similar trials or studies performed in the past year.
19. Attachments Required: Copies of protocol or summary, Helsinki Committee approvals, and patient information/informed consent forms for each trial.

Declaration: A declaration affirming the accuracy and completeness of the provided information.

This form is subject to review and confirmation by the insurers and is not an offer to insure.

Contact Information:
- Customer Relations Center and Information: 3455
- Main Office: 53 Derech Hashalom Road, Givata'im 5345433
- Fax for pension claims: 03-7337942
- Website: [www.fnx.co.il](http://www.fnx.co.il)
- Email: [tpensya@fnx.co.il](mailto:tpensya@fnx.co.il)

Please note that this information is based on the content provided in the document as of November 2016, and there may have been updates or changes since then.

טופס Insurance Application Legal Liability Insurance for Clinical Trials - ביטוח כללי חלופה נגישה - כרגע לא קיימת.

טופס Insurance Application Legal Liability Insurance for Clinical Trials - ביטוח כללי מילוי מקוון - כרגע לא קיים.

טופס Insurance Application Legal Liability Insurance for Clinical Trials - ביטוח כללי הזמנת טופס בדואר - כרגע לא קיימת אופציה.

טופס Insurance Application Legal Liability Insurance for Clinical Trials - ביטוח כללי להורדה והדפסה - טופס PDF זמין במעלה העמוד.

הגרסה הנגישה של הטופס (טקסט בלבד):

November 2016 | Page 1 from 2 | 300201075
Customer Relations Center and Information: *3455 ׀ 2 Rehavam Zeevi, Givat Shmuel
Main Office: 53 Derech Hashalom Road, Givata'im 5345433 ׀ Fax for pension claims: 03-7337942
www.fnx.co.il ׀ tpensya@fnx.co.il
The Phoenix Pension and Provident
Insurance Application Form Legal Liability Insurance for Clinical Trials
1. Named Insured: ____________________________________ I.D. Number: ____________________________________
Address: ____________________________________ Telephone: ____________________________________
Email: ____________________________________
2. Description of Business: ____________________________________
3. Date Business was established: ____________________________________
4. Other parties to be covered by the Policy: ____________________________________
5. Hospital(s) and/or Institution(s) where the trials are to be performed: ____________________________________
6. Title (s) of the Trial(s) for which insurance is sought: ____________________________________
Phase: I___ II __ __ III ____ Other: ___________________________
7. No. of Trial Subjects: ____________________________________
8. Minimal age of Trial Subjects: ____________________________________
9. Status of Helsinki Committee approvals: ____________________________________
Local: Approval Date: ___________________________ Expiration: ___________________________
Ministry of Health Date: Expiration:
10. Date the Trial is to begin: ____________________________________
11. Date the Trial is to end: ____________________________________
12. Time of Trial per participant: ____________________________________
13. Are all trials are to be conducted in full accordance with:
(please give full details if any reply is “No”): _____________________________________________________________
a. Public Health Regulations (Medical Experiments Involving Human Subjects)--1980?  Yes  No
b. Protocols approved by the relevant Helsinki Committee(s) including any special conditions required by a committee
as a condition of approval?  Yes  No
c. Ministry of Health--Pharmaceutical Division Guidelines of September,?  Yes  No
d. Any directive on Good Clinical Practice (GCP)? Yes Which directive? _____
e. A Consent Form to be signed by each Trial Subject conforming to those set forth in the: Ministry of Health—
Pharmaceutical Division Guidelines of 1999?  Yes  No
14. If a medication, pharmaceutical or medical device is being investigated in the Trial(s), is product liability insurance in
force?  Yes  No
15. All trials are to be conducted in Israel?  Yes  No
If not, state other countries in which trials are to take place:
___________________________________________________________________________________________________________________________________________________ _
_____________________________________________________________________________________________________________________________________________________
16. Requested Limits of Liability
17. Give details of incidents during the last 5 years resulting in death, injury, disease or illness (physical or mental) to
patients or volunteers participating in similar or related clinical trials, and any circumstances which might give rise
to a claim for compensation against the Contracting Party, the Sponsor, the Investigator or the manufacturer of the
medication or device which is to be investigated in the Trial for which coverage is sought.
Include date of event, date of claim, description of injury, amount of claim, status and outcome. (Attach a separate page
if necessary)
___________________________________________________________________________________________________________________________________________________ _
_____________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
Dummy TextNovember 2016 | Page 2 from 2 | 300201075
Customer Relations Center and Information: *3455 ׀ 2 Rehavam Zeevi, Givat Shmuel
Main Office: 53 Derech Hashalom Road, Givata'im 5345433 ׀ Fax for pension claims: 03-7337942
www.fnx.co.il ׀ tpensya@fnx.co.il
The Phoenix Pension and Provident
18. If not included in the Protocol to be submitted with this application, provide summary of similar or related Trials/Studies
performed in the last 12 months. Include the dates, a description, the Phase of the Trial and the number of patients or
volunteers participating. (Attach a separate page if necessary):
___________________________________________________________________________________________________________________________________________________ _
_____________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________ _
_____________________________________________________________________________________________________________________________________________________
19. For each trial to be insured, you must attach a copy of:
A. Protocol or Summary of Protocol. (Must be provided in English)
B. Helsinki Committee (s) Approval (s).
C. Patient Information/Explanation and Informed Consent Form to be used in the trial. (Please provide in English,
if possible)
I hereby declare that all of the answers above are correct, complete and straightforward and that I have not concealed any
material facts relating to the trial(s) to be insured or the assessment of the risks involved. I hereby acknowledge and agree that
the information provided above will be relied upon by the insurance company and shall serve as a basis of the policy.
Signed on behalf of the Contracting Party:
Name:__________________________________ Date: __________________________________ Position: __________________________________
This proposal is subject to review and written confirmation on behalf of the insurers and shall not be construed as an offer to insure.

קרא עוד

מה תמיד שואלים לפני שממלאים טופס Insurance Application Legal Liability Insurance for Clinical Trials - ביטוח כללי?

רשמנו עבורך מדריך מפורט שעונה בדיוק על השאלה הזו וכמובן גם עוזר במילוי טופס Insurance Application Legal Liability Insurance for Clinical Trials – ביטוח כללי, אנו ממליצים לקרוא את המדריך מתחילתו ועד סופו והדברים יהיו ברורים יותר.
בתחילת המדריך צירפנו עבורך קישור להורדת טופס Insurance Application Legal Liability Insurance for Clinical Trials – ביטוח כללי. יש ללחוץ על הכפתור ואתה תעבור להורדת הטופס. במידה והינך גולש ממכשיר סלולרי או אייפון לדוגמא שלא מתחיל את ההורדה בצורה מיידית, תוכל לגלול מטה במאמר אל הטופס לצפייה ישירה ולהוריד אותו משם אל המכשיר.
בכל מדריך אנו מצרפים את הגורמים הרלוונטיים אשר יכולים לסייע לכם במילוי הטופס המדובר, ניתן לקרוא במדריך ולקבל את הטלפונים והמיילים של הלשכות הרלוונטיות לסיוע במילוי טופס Insurance Application Legal Liability Insurance for Clinical Trials – ביטוח כללי.

גוף שיתמוך בשאלות על טופס Insurance Application Legal Liability Insurance for Clinical Trials - ביטוח כללי

פקס: 03-7336914
כתובת לשליחת מכתבים: רחוב רחבעם זאבי 2, גבעת שמואל
עורכי האתר "טופס קל"
עורכי האתר "טופס קל"

סורקים את הרשת בכדי להביא לכם את כל הטפסים הנדרשים למילוי מול הרשויות, ומצרפים לכם מדריכים מפורטים בכדי להקל על התהליך.

הטופס שייך לקטגוריות: חברות ביטוח, ביטוח הפניקס, הצעה
טופס קל » חברות ביטוח » ביטוח הפניקס » הצעה » טופס Insurance Application Legal Liability Insurance for Clinical Trials – ביטוח כללי

*לידיעתכם: האתר טופס קל הוא פורטל טפסים פרטי ואינו קשור בשום צורה לגופים ממשלתיים כאלו או אחרים. המידע מוגש לטובת הציבור אך עלולות ליפול טעויות במידע או שהמידע המוצג עלול להיות לא מעודכן ולכן אין להסתמך על המידע בצורה מוחלטת אלא יש לבדוק את הטפסים בטרם שליחתם עם הגופים המנפיקים.

טפסים נוספים שאולי תצטרכו למלא:

כתיבת תגובה

האימייל לא יוצג באתר. שדות החובה מסומנים *

ראשי פרקים של טופס Insurance Application Legal Liability Insurance for Clinical Trials - ביטוח כללי להורדה

דילוג לתוכן