1a.
Name:
1b.
Are you registered for GST purposes?
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)
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?
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.
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?
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:
()
o.
Clerical/Administrative:
TOTAL:
8a.
Are you currently insured for malpractice insurance?
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?
If 'Yes' , please complete the table below for the last 3 years you were insured:
9.
Have you ever had a liability insurer:
a.
Decline a proposal?
b.
Impose special terms?
c.
Decline to renew your insurance?
d.
Cancel your insurance?
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?
If 'Yes' , please provide details:
11.
Does the proposer act as a charitable institution?
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?
If 'Yes' , please provide details:
13a.
What is the professional nature of the establishment?
13b.
Has there been any change in the professional nature of the establishment?
If 'Yes' , please provide details:
14.
Please provide the approximate division of patients between:
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?
If 'Yes' , please give details stating by whom the treatment is given:
18.
Does the proposer have:
a.
An ICU (Intensive Care Unit)?
b.
CAT scanners, MRI equipment or similar?
c.
Pathology laboratory(ies)?
If 'Yes' to Q.18c % Revenue
%
19i.
Please provide the following details about number of beds now available:
19ii.
What is the overall occupancy rate for all the beds maintained during the last 12 months?
%
20.
Have your or any Principal been (or are they) a member of any Joint Venture?
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.
21.
Have you ever undertaken, or are your likely to undertake, work overseas?
If 'Yes' , please provide the following details of such work:
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.
23.
Does the proposer require specific Registered Medical Practitioners and/or Consultants to be covered under the proposed insurances?
If 'Yes' , please provide the following details of such work:
24a.
Does the proposer have any Medical or Nursing teaching facilities?
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?
If 'Yes' , please provide details:
24c.
Matron’s name, qualification, year obtained and how long in this position:
25.
Do you operate clinics?
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?
26b.
If 'Yes' , do you obtain written confirmation that all providers of such rides/flights maintain current public liability insurance?
27.
Does the proposer envisage any substantial changes in your activities or major new developments within the next 12 months?
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?
If 'Yes' , please provide details:
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?
If 'Yes' , please give details:
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)?
If 'Yes' , please give details:
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)?
If 'Yes' , please give details:
d.
Has any Principal or staff member ever been subject to disciplinary proceedings for professional misconduct?
If 'Yes' , please give details:
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:
31a.
Do you have a documented Risk Management Program (consistent with Australian Standard AS/NZS 4360:2004) which addresses your professional duty risk?
If Yes , please copy & paste or email a copy:
31b.
What date was that program implemented?
31c.
Is the program independently reviewed/monitored/audited?
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?
If 'Yes' , please provide details:
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.):
$
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.
If 'Yes' , please state the date from which retroactive cover is required:
34.
Do you require Employment Practices Liability cover, subject to additional premium?