Medical Malpractice Insurance

To receive a quote, please complete the form below. Once we have determined what part of the health industry you perform in, we will ask additional appropriate questions which relate to your industry so that we can provide a competitive and relative cover.

If you would prefer to talk to a broker first, please call Liability Brokers between 8.15am and 5.15pm E.S.T. business days and receive an indicative quote over the phone.


Client Details

Insured Name:
Trading Name:
ABN No.(if applicable):
Full Address:
Email Address:

Website Address (if applicable):

Telephone No:
Start date of business:

If you have spoken to someone in our office, please note their name here so that this form can be processed by them as they will know something about you already.

Brokers Name:

   

Professional Duties

What is your occupation:

Please provide a full description of Your business activities.

   

Quote Required

Please nominate the amount of covers you require:

Malpractice Insurance
(Professional Indemnity)  .    

 Public Liability
$1,000,000 Not required
$2,000,000 $5,000,000
$5,000,000 $10,000,000
$10,000,000 $20,000,000

 

Underwriting questions

No. of full time people in the business
.
No. of part time people in the business
.
Gross Revenue - last year
Australia If Nil, put in "0"    
Elsewhere If Nil, put in "0"    
.
Estimated Revenue for next year
Australia If Nil, put in "0"    
Elsewhere If Nil, put in "0"    

If you conduct or have conducted business in overseas countries, please provide details:

   

Please state the percentage of Your activities (based on income) for each State
ACT NSW NT QLD SA TAS VIC WA O/Seas
% % % % % % % % %

   

Insured's History

During the past 10 years, has any claim been made against you, your principals, employees or consultants for Medical Malpractice, Public Liability, Professional Liability or had any circumstance been notified to the insurers that might give rise to a claim?
Yes    No

If you answered "Yes" above, please give details.

Is any applicant aware of any claim or circumstances that might give rise to a claim against the Business or any prior business of any of their present or former Partners, Principals or Directors, which matter is not referred to above?
Yes    No

If you answered "Yes" above, please give details.

Has any applicant ever been subject to disciplinary proceedings for professional misconduct?
Yes    No

If you answered "Yes" above, please give details.

Has any applicant ever had a Liability Insurer decline to continue the applicant's insurance or cancel their insurance?
Yes    No

If you answered "Yes" above, please give details.

Have you (or any person receiving cover under this policy) ever:
  • Been involved in a company that has been declared bankrupt or insolvent?
  • Been liable for any civil offence or pecuniary penalty?
  • Been charged or convicted for any criminal offence?
  • Been charged or convicted for fraud, theft or dishonesty?

Yes    No

If you answered "Yes" to any of the above, please give details.


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Declaration

By submitting this Declaration, the Applicant declares that:
  • they are authorised by each of the other Applicants to make this Declaration,
  • the contents of the Declaration are true and complete,
  • they are under a continuing obligation to immediately inform the insurer of any change in the particulars or statements contained in this Declaration or in the accompanying documents up until the contract is entered into,
  • they authorise the insurer to give or obtain from other insurers or insurance reference bureaus or credit reporting agencies, any information about this insurance or any other insurance held by the Applicant/s.
  • they are not involved in any of the activities or industries that are noted under the Uninsured Activities section at the top of this form.

Name of person making this declaration:

 


 

Duty of Disclosure (What you must tell us)
Under the Insurance Contracts Act 1984 (the Act), you have a Duty of Disclosure. You are required before you enter into, renew, vary, extend or reinstate your Policy, to tell us everything you know and that a reasonable person in the circumstances could be expected to know, is a matter that is relevant to our decision whether to insure you, and anyone else to be insured under the Policy, and if so, on what terms.
You do not have to tell us about any matter:
  • that diminishes the risk
  • that is of common knowledge
  • that we know or should know in the ordinary course of our business as an insurer, or
  • which we indicate we do not want to know.
  • If you do not tell us
If you do not comply with your Duty of Disclosure we may reduce or refuse to pay a claim or cancel your Policy. If your non-disclosure is fraudulent we may treat this Policy as never having worked.

Claims Made Policy
The Professional Indemnity section of this Policy operates on a 'Claims made and notified' basis. This means that the Policy covers you for Claims made against you and notified to us during the Period of Insurance.
This Policy does not provide cover in relation to:

  • acts, errors or omissions actually or allegedly committed prior to the retroactive date of the Policy (if a date is specified);
  • claims made after the expiry of the period of insurance even though the event giving rise to the Claim may have occurred during the period of insurance;
  • claims notified or arising out of facts or circumstances notified (or which ought reasonably to have been notified) under any previous Policy;
  • claims made, threatened or intimated against you prior to the commencement of the period of insurance;
  • facts or circumstances of which you first became aware prior to the period of insurance, and which you knew or ought reasonably to have known had the potential to give rise to a Claim under this Policy;
  • Claims arising out of circumstances noted on the proposal form for the current period of insurance or on any previous proposal form.
Where you give notice in writing to the insurer or any facts that might give rise to a claim against you as soon as reasonably practicable after you become aware of those facts but before the expire of the period of cover, you may have rights under Section 40(3) of the Insurance Contracts Act 1984 to be indemnified in respect of any claim subsequently made against you arising from those facts notwithstanding that the claim is made after the expiry of the period of cover. Any such rights arise under the legislation only. The terms of the Policy and the effect of the Policy is that you are not covered for claims made against you after the expiry of the period of cover.