Medical Malpractice Insurance Application Form

As part of our Privacy Policy, the information that you give us here is so that we can obtain a quote for your particular insurance concerns and will only be provided to the insurers with whom we obtain quotes through on your behalf. If you want more information about our Privacy Statement, please refer to our website for full details.

Current Insurance Information

Policy Due Date *

Current Insurer *

Current Annual Premium ($)

How many years of Continuous Insurance *

Personal Details

First Name *

Last Name *

Is this for an Individual or an Entity *

Gender *

Date of Birth *

Email *

Please enter your email, so we can follow up with you.

Best Contact Number *

Practice Details

Name and Address of Main Practice *

State where you Practice *

Are you a Practice Owner *

Yes
No

Services

Specialisation *

Estimated gross private billings for next 12 months (in $) *

What to include Do NOT record a Gross Billings band. A dollar amount is required for all healthcare billings for which you require insurance cover.Gross Annual Billings are the total billings generated by you from all areas of your practice for which you require indemnity from us within the financial year, whether the funds are retained by you or not, and before any apportionment or deduction of expenses and/or tax. This includes work performed in your name or work for which you are personally liable, including but not limited to: Medicare benefits payments by individuals payments by the Commonwealth Department of Veterans’ Affairs, workers’ compensation schemes and third party and/or vehicle insurers income received from other healthcare services provided by you such as professional fees, writing articles, incentive payments and overseas work for which we have agreed to extend indemnity under the policy. What not to include You do not need to include any billings or income from healthcare services that you provide for which you have access to indemnity from the public hospital’s indemnity scheme or your employer.

Add Additional Healthcare Specialisation

Yes

Specialisation 2

Estimated gross private billings for next 12 months (in $)

Additional Information (Other or specific services)

Add Additional Healthcare Specialisation 3

Yes

Specialisation 3

Estimated gross private billings for next 12 months (in $)

Additional Information (Other or specific services)

Qualification

Qualifications *

Instituition *

Year Obtained *

Country *

Membership

College name

Year Fellowship Obtained

Are you currently in a training program?

Yes
No

Registration Details

Are you working on a 422, 457, or any other temporary working visa whilst in Australia? *

Yes
No

AHPRA registration number *

Year first registered in Australia *

Have you ever practiced under a different name? *

Yes
No

Years in Private Practice *

Any other additional information that you may want to provide for an indicative quote

Have you ever been refused registration, been suspended or de-registered in any country (including voluntary relinquishing your registration)? *

Yes
No

Have you ever had any conditions, limitations, notations, reprimands or undertakings imposed on your registration in any country (anything that would be considered an adverse decision to having standard registration)? *

Yes
No

Insurance & Claims History

Over the course of your practice of medicine have you responded to any complaints from patients or submitted information to AHPRA or any other healthcare registration or regulatory authority in any country? *

Yes
No

Have you ever been involved in an audit (including Medicare/prescribing), inquiry, investigation, complaint, coronial inquest in relation to your conduct as a provider of healthcare services? *

Yes
No

Have you or your practice ever been involved or required to respond to any complaints, claims, demands, suits or legal actions which have arisen out of your provision of Healthcare Services? *

Yes
No

Are you aware of any act, error, omission or circumstance that has arisen from your provision of healthcare services that could or should have been notified under any current or prior insurance policy or other arrangement under which you are or were entitled to indemnification? *

Yes
No

Have you ever been charged with, convicted of or found guilty of a criminal offence in any country? *

Yes
No

Has any privilege or authority been limited or adverse action ever been taken against you by an employer, medical board, hospital, health authority, medical college or statutory body in any country? *

Yes
No

Is there any circumstance or situation, past or present, which you are aware of or should reasonably be aware of that relates to your provision of Healthcare Services which is likely to give rise to any claim that would be covered under this policy or that should have been notified to a previous insurer? *

Yes
No

Have you ever been involved in any type of employment or training dispute arising from the provision of Healthcare Services including those services provided by you to a healthcare providing organisation or services provided to you by an employee or contractor? *

Yes
No

Have you ever held medical or professional indemnity insurance in the past? (list below) *

Yes
No

Has any application for or renewal of medical or professional indemnity insurance ever been declined or cancelled, had a loading, deductible or special condition placed on your policy or have you ever been provided a policy with a reduced level of cover? *

Yes
No

Have you ever provided healthcare without medical indemnity insurance in place (your own or a policy under which you were entitled to cover) or declined to take run-off cover for a period(s) where you were not practicing? *

Yes
No

How did you find us *