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

Brokers Name:

Client Details

Insured Name

Trading Name

ABN No.(if known)

Full Address

Email Address

Website Address

Phone No. *

When did the business start (year)?

Professional Duties

Please provide a full description of Your business activities.

Risk Information

Is the applicant licensed to practice at the address stated above?
Yes    No

Do all staff performing services have the minimum qualifications required to the general accepted standards of the Business Activities / Services provided?
Yes    No

Please list the professional bodies or associations of which the applicant is a member:

Do you manufacture, alter, repair, repackage or import any Products for sale?
Yes    No
* Please note that there is no cover for private label products.

What percentage of your turnover is derived from the sale of Products?
 %

Do you use a medical history / client information form in all cases?
Yes    No

Do you use a hold harmless or informed consent form?
Yes    No

Quote Required

Please nominate the amount of covers you require:

Professional Indemnity

$1,000,000

$2,000,000

$5,000,000

$10,000,000

Public Liability

Not required

$5,000,000

$10,000,000

$20,000,000

* Standard cover is $1,000,000 Malpractice & $10,000,000 Public Liability cover

Services Provided

Please change to a "Yes" the services you provide.

First Aid Services   No Yes

First Aid Training   No Yes

Other-Not above   No Yes

If Other, please give details

Do you envisage any major changes in your activities?
Yes    No

If "Yes", please provide full details:

Underwriting questions

No. of full time people in the business  

No.of part time people in the business  

Gross Revenue - last year   If Nil, put in "0"

Australia  

Overseas  

Estimated for next year   If Nil, put in "0"

Australia  

Overseas  

State the percentage of Your activities (based on income) applicable to each State

Contractors

Do you employ contractors, sub-contractors?
Yes    No

Do You require cover for sub-contractors?
Yes    No

If "NO", do You insist they carry their own insurance?
Yes    No

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

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

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

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

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?

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

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.