On-line Medical, Health & Allied Establishments Malpractice Insurance


Thank you for considering our on-line medical, health and allied establishments malpractice insurance service.   Because Greater National Group is an insurance broker, not an insurance company, we will process your application with major insurance companies in order to find the right medical, health and allied establishments malpractice insurance for you.

Please fill in the following form as fully as possible, then click 'submit' at the end of the form.
You can use the TAB key to move to the next field. We will respond with your terms as soon as we have researched the market for the right available deals that fit your requirements.


Your Details
1a. Name:
Full legal name of each natural person & incorporated body to be insured as well as any unincorporated business or trading names Date(s) of Commencement
1b. Are you registered for GST purposes?
Yes No
1c. If less than 5 years, please copy & paste or email a resume of partners’/directors’ prior experience.
2. Address
a. Registered Office
b. Other Locations
3. Principals’ previous business (incoming)
Trading name of any prior professional business conducted by a Principal Date name changed/business ceased
4. Prior corporate entity:
Has the name of the person, firm or incorporated body detailed in answer to Question 1 been changed, or has any other business been purchased or has any merger or consolidation involving your businesses taken place?
Yes No
If 'Yes', please detail changes in chronological order:
5. Name(s) of owner(s), Principals or partners and details of their professional experience/qualifications.
If the establishment is not administered by the owner(s) or partner(s), please outline administrative structure.
In particular, state name, professional qualifications, years of experience of administrator.
      Years practising as Principal  
Name and Title Qualifications Date Qualified This Practice Prev. Practice Name of Previous Practice
6. Is the proposer a member in good standing of a professional association or society that is associated with this type of business or activity?
Yes No
If 'Yes', please give full details of membership status:
7. State the number of employees in each of the following classifications:
This policy is designed to cover claims made against the proposer’s establishment and/or employees, provided such employees are not registered medical practitioners. If cover is also required for claims made against registered Medical Practitioners or other consultants who are not employees, please refer to Question 22.
a. Surgeons:
b. Doctors:
c. Anaesthetists:
d. Interns:
e. X-ray Technicians:
f. Laboratory Technicians:
g. Pharmacists:
h. Registered Nurses:
i. Enrolled Nurses:
j. Midwives:
k. Nurse Anaesthetists:
l. Attendant Carers:
m. Undergraduate or Student Staff:
n. Other medical, health or allied employees: (please specify)
o. Clerical/Administrative:
TOTAL:
Insurance History
8a. Are you currently insured for malpractice insurance?
Yes No
If 'Yes', please complete the table below for the last 3 years:
8b. If you are not, have you ever been insured for malpractice insurance?
Yes No
If 'Yes', please complete the table below for the last 3 years you were insured:
Name of Insurer Period Insured Sum Insured ($) Excess ($)
9. Have you ever had a liability insurer:
a. Decline a proposal?
Yes No
b. Impose special terms?
Yes No
c. Decline to renew your insurance?
Yes No
d. Cancel your insurance?
Yes No
If the answer to any of the above is "Yes", please provide details:
10. Is the proposer maintained in whole or in part by public or private funds or endowment?
Yes No
If 'Yes', please provide details:
11. Does the proposer act as a charitable institution?
Yes No
If 'Yes', please state percentage of full charity patients:
12. Is the proposer duly licensed in accordance with law to practise at the address(es) specified in Question 4?
Yes No
If 'Yes', please provide details:
Your Professional Activities
13a. What is the professional nature of the establishment?
13b. Has there been any change in the professional nature of the establishment?
Yes No
If 'Yes', please provide details:
14. Please provide the approximate division of patients between:
a. General/ Medical % h. Psychiatric %
b. Surgical (major) % i. Drug/Alcohol dependency %
c. Surgical (minor) % j. Elective Cosmetic %
d. Day Surgery % k. Obstetrics/Maternity %
e. AIDS/HIV % l. Allied Health Therapy %
f. Senile or Aged % m. Casualty/Emergency %
g. Palliative % n. Other (please specify) %
15. What diagnosis or surgical procedures are performed other than as referred to in Question 14?
16. State number of X-ray machines owned or operated and whether they are used for diagnosis or treatment or both. Please state by whom treatment is given.
17. Does the proposer give radium or other radio-active treatment?
Yes No
If 'Yes', please give details stating by whom the treatment is given:
18. Does the proposer have:
a. An ICU (Intensive Care Unit)?
Yes No
b. CAT scanners, MRI equipment or similar?
Yes No
c. Pathology laboratory(ies)?
Yes No
If 'Yes' to Q.18c % Revenue (disclosed in Q.30(a)) %
19i. Please provide the following details about number of beds now available:
a. Emergency Ward Beds b. Day Surgery Beds
c. Maternity Beds d. Other Hospital Beds
e. Nursing Home Beds f. Self Care Units
g. Others - please give details
19ii. What is the overall occupancy rate for all the beds maintained during the last 12 months? %
Joint Ventures
20. Have your or any Principal been (or are they) a member of any Joint Venture?
Yes No
If Yes, please copy & paste or provide information in respect of each such Joint Venture. Additional information may be requested depending on the nature, size and type of Joint Venture.
Overseas Work (Outside Australia)
21. Have you ever undertaken, or are your likely to undertake, work overseas?
Yes No
If 'Yes', please provide the following details of such work:
Country Type of Work Dates of Commencement/Closure Annual Income ($)
Miscellaneous
22. Does the proposer regularly ensure and record that all Registered Medical Practitioners and other Consultants are members of a Medical Defence Organisation, or are otherwise fully insured for their own Malpractice? If No, please refer to the note to Question 7.
Yes No
23. Does the proposer require specific Registered Medical Practitioners and/or Consultants to be covered under the proposed insurances?
Yes No
If 'Yes', please provide the following details of such work:
Name Qualifications Service Relevant Experience Employee
24a. Does the proposer have any Medical or Nursing teaching facilities?
Yes No
If 'Yes', please provide details:
24b. Does and will the proposer ensure that competent and adequately trained staff only will be employed and that staff are properly supervised?
Yes No
If 'Yes', please provide details:
24c. Matron’s name, qualification, year obtained and how long in this position:
25. Do you operate clinics?
Yes No
If 'Yes', please state:
a. Kind of clinic:
b. Whether free, part-pay or full pay?
c. Number of:
i. Employed Clinic Physicians and Interns:
ii. Nurses:
iii. Patients per year:
26a. Does the proposer conduct fund raising functions which involve amusement rides, pony rides, balloon rides and the like?
Yes No
26b. If 'Yes', do you obtain written confirmation that all providers of such rides/flights maintain current public liability insurance?
Yes No
27. Does the proposer envisage any substantial changes in your activities or major new developments within the next 12 months?
Yes No
28. Is there any further information that should be made known to Greater National Group so that a proper estimate of the risk may be formed?
Yes No
If 'Yes', please provide details:
Claims and Circumstances
29. Please answer the following questions after enquiry within your organisation.
a. During the past 10 years has any Claim been made, or has negligence been alleged, against any entity or individual to be insured by this insurance (including any prior corporate entity and any of the present or former Principals), or have any circumstances which may give rise to a claim against any of these been notified to insurers?
Yes No
If 'Yes', please give details:
Year Notified Insured With Claimant Nature of Problem Amount Paid and/or
outstanding
b. Are there any circumstances not already notified to insurers which may give rise to a Claim against any entity or individual to be insured by this insurance (including any prior corporate entity and any of the present or former Principals)?
Yes No
If 'Yes', please give details:
Name of Practice and
Principal		 Claimant Nature of Problem Estimate
c. Are there any Claims against previous practices which have been identified in Questions 3 or 4 of this Proposal, which may give rise to a Claim against any entity or individual to be insured by this insurance (including any prior corporate entity and any of the present or former Principals)?
Yes No
If 'Yes', please give details:
Name of Practice and
Principal		 Claimant Nature of Problem Amount Paid and/or
outstanding
d. Has any Principal or staff member ever been subject to disciplinary proceedings for professional misconduct?
Yes No
If 'Yes', please give details:
Name of Practice and
Principal/Staff Member		 Claimant Nature of Problem Amount Paid and/or
outstanding
Revenue
30a. Gross revenue for the last 12 months:
Australia $
30b. Estimated gross revenue for the next 12 months:
Australia $
Include fees paid to sub-consultants appointed by you.
Exclude fees collected for disbursement to consultants appointed by your client together with travelling, accommodation or similar expenses reimbursed by your clients
30c. Please provide a percentage breakdown of the fee income disclosed in Question 18(a) by State or Territory:
NSW  VIC  QLD  SA  WA  ACT  TAS  NT  O/S
               
Risk Management
31a. Do you have a documented Risk Management Program (consistent with Australian Standard AS/NZS 4360:2004) which addresses your professional duty risk?
Yes No
If Yes, please copy & paste or email a copy:
31b. What date was that program implemented?
31c. Is the program independently reviewed/monitored/audited?
Yes No
If 'Yes', please provide details:
31d. When was that program last reviewed and updated to ensure that it complies with the current standards applying to your profession?
31e. What are the highlights of the program which you have implemented to reduce/manage risk related to breach of professional duty as they related to your practice?
31f. Is there a principal/director/partner responsible for the oversight of risk management within your practice?
Yes No
If 'Yes', please provide details:
Cover Required
32a. Please state amount of preferred Total Sum Insured: $
32b. Please state amount of preferred excess. (N.B. Your policy will be subject to a minimum excess.): $
Retroactive Cover
33. Do you require retroactive cover which may be subject to additional premium?
Retroactive cover extends cover under the Policy to liability arising from work carried out prior to the inception of the Policy to which this Proposal relates.
There will be no cover for Claims arising from a Known Circumstance as at Policy inception.
Yes No
If 'Yes', please state the date from which retroactive cover is required:
Optional Extensions Entity Cover Employment Practices Liability Fidelity
34. Do you require Employment Practices Liability cover, subject to additional premium?
Yes No


Duty of Disclosure:
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?
Yes No
If so, please provide details:
I/We hereby declare that:
My/Our attention has been drawn to the Important Notices accompanying this form and further I/we have read these notices carefully and acknowledge my/our understanding of their content. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this form and the inception date of the insurance to which this relates I/we shall give immediate notice thereof. I/We authorise GNG and the Insurer to collect or disclose any personal information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the Privacy Policy. I/We also confirm that I/we am/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this form and I/we complete this form on their behalf.
Any other comments, requests or relevant information you need to add:
Contacting you about your quote:
In order to select the most appropriate cover for you, it may be important to discuss quote details in person. Please leave a contact phone number and best time to call to facilitate this.
Your full name:
Company/Business/Name of Applicant to be Insured:
ABN:
Your phone number (please include area code):
Your mobile phone number:
Best time(s) to call:
Please send my quote by (select at least one):
email phone fax mail
Your email address:
Your website address:
Your fax number:
Your postal address:
Country: