On-line Medical Professionals' Professional Indemnity Insurance


Thank you for considering our on-line medical professionals' professional indemnity 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 professionals' professional indemnity 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.


1a. Please state the limit of indemnity required: $
1b. What excess do you wish to pay towards a claim?: $
2. Do you currently have professional indemnity insurance?
Yes No
If yes, please provide details below:
Expiry date:
Insurance company:
Indemnity limit: $
Excess: $
Premium: $
3. Full business description for which insurance is required:
4. Particulars of Principal:
Name of Principal Qualifications Professional Associations
Resume/CV: If not contained on your website, please copy & paste or email a brief resume for each Principal and/or Director.
5. 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:
6a. Have there been any major changes in you Business activities in the last 24 months?
Yes No
If Yes, please provide details:
6b. Do you anticipate any major changes in you Business activities in the next 24 months?
Yes No
If Yes, please provide details:
Turnover / Patients
7. Please indicate total Turnover (Turnover means the total of all income generated by the Business from all areas of the Business for which Business Medical Indemnity insurance is required whether retained by the Business or otherwise and before any apportionment or deduction of any expenses and/or tax):
7a. Actual Turnover last financial year: $
7b. Estimated Turnover current financial year: $
7c. Estimated Turnover forthcoming financial year: $
8. Please indicate the total number of patients for which services were provided:
8a. Last financial year:
8b. Estimate for current financial year:
8c. Estimate for forthcoming financial year:
9. Please indicate the total number services provided:
9a. Last financial year:
9b. Estimate for current financial year:
9c. Estimate for forthcoming financial year:
Apportionment Turnover / Patients
10a. Please advise the percentage of Turnover as follows:
Percentage of Gross Income:
NSW  VIC  QLD  SA  WA  TAS  NT  ACT  O/S
%  %  %  %  %  %  %  %  %
10b. Please advise the percentage of patients as follows:
Percentage of Patients:
NSW  VIC  QLD  SA  WA  TAS  NT  ACT  O/S
%  %  %  %  %  %  %  %  %
Previous Business Medical Indemnity / Professional Indemnity Insurance History:
11. Does your Business currently or has your Business previously held Business Medical Indemnity / Professional Indemnity insurance?
Yes No
If Yes, please complete details in the table listing each individual insurer:
Period of Insurance Limit Liability / Excess
From To Name of Insurer Limit Excess
Limit of Liability including one automatic reinstatement) and excess required
12a. Please indicate the limit(s) of liability (sum insured) for which your Business requires a quotation:
$3,000,000 $5,000,000 $10,000,000 $15,000,000 $20,000,000
12b. If your Business requires a limit(s) of liability other than as detailed above, please state the required amount. (Note: Maximum limit of liability available is $20,000,000): $
12c. A minimum excess of $10,000 each claim will apply to the policy issued. Please state if your Business would like a quote for higher excess options:
Retroactive Indemnity
13a. Does your Business require insurance for claims that may be made arising from or attributable to incidents that may have occurred in any period prior to the requested commencement date of insurance?
Yes No
If Yes, please complete the following:
13b. Please advise the date from which your Business requires Retroactive Indemnity:
13c. If your Business is currently insured please advise the Retroactive date recorded on its current insurance policy:
Note: This will mean that if Retroactive Indemnity is granted your Business will be covered for claims made during the period of insurance for incidents that occurred after the agreed Retroactive Date excluding any claims or circumstances of which it was aware at the time of completion of this Proposal Form.
13d. Is the Business Description for which you seek Retroactive Indemnity the same as the Business Description declared in Question 3?
Yes No
13e. Please provide details in the following table, relative only to the period for which Retroactive Indemnity is required:
Period Prior Business activities
for which
Retroactive Indemnity is required		 Estimated Turnover from prior activities
From To
Business activities outside of Australia
14. Does your Business engage in activities outside of Australia for which insurance cover is required?
Yes No
If Yes, please advise location, key activities and percentage of turnover:
Note: No cover can be provided for business activities undertaken in the USA or Canada or jurisdictions to which the laws of USA or Canada apply.
Medical Research and/or clinical trials
15. Do the activities of your Business include medical research and/or clinical trials for which your Business requires cover?
Yes No
If Yes, please email/fax/mail the following information for each medical research and/or clinical trial:
  • Are research/trials projects initiated solely by your Business
  • Are research/trials projects undertaken on behalf of third parties e.g. drug companies, product manufacturers, research foundations etc
  • Is your Business entitled to and/or is your Business provided with indemnities by third parties in relation to research/trials projects undertaken by your Business
  • Does your Business provide indemnities to third parties in relation to research/trials projects undertaken
  • Are volunteers advised where double blind studies are undertaken
  • Do research/trials projects involve female volunteers of child-bearing age
  • Do research/trials projects involve testing or experimenting in obstetrics, paediatrics, transplant and/or surgery, human embryo research, genetic engineering or artificial organ research
  • Are there consenting procedures/protocols, consenting documentation and consent forms
Your Employees - Excluding Medical Practitioners
16. Please advise the total number of full or part time staff, including allied health professionals, employed by your Business
Category of employee Total number of full time equivalent employed:
Midwives
Nurse Practitioners
Nurses
Technicians
Clerical/Administrative
Other (please provide details)
Total
Medical Practitioners in your business
17a. Does your Business employ medical practitioners?
Yes No
If Yes, please advise the percentage of all employed medical practitioners who are insured with or proposed to be insured through Greater National Group: %
17b. Does your Business require all medical practitioners to maintain their own medical indemnity insurance?
Yes No
Note: Each employed or contracted registered medical practitioner must at all times have in place their own medical indemnity insurance unless an extension is sought and is granted to cover registered medical practitioners under this insurance.
17c. Does your Business require employed medical practitioners to be noted as insured parties under this insurance in lieu of them maintaining their own separate medical indemnity insurance?
Yes No
17d. Does your Business required contracted medical practitioners to be noted as insured parties under this insurance in lieu of them maintaining their own separate medical indemnity insurance?
Yes No
If Yes, please provide details of terms and conditions of contract in relation to indemnity and insurance provisions:
17e. If you answered Yes to questions 17c or 17d, please provide or attach a full listing detailing:
  • Name of medical practitioner
  • Qualifications/Specialty
  • Nature of work undertaken
  • Date commenced employment (and date ended - if applicable)
  • Date contracted (and end date - if applicable)
  • Practice location
Claims and circumstances declaration
After making appropriate enquiries, are you aware, or is any principal, partner, director, employee or agent of your Business aware of:
18a. any claims having been made against your Business, its principals, partners, directors, employees or agents, alleging medical malpractice, negligence or breech of professional duty?
Yes No
18b. any occurrences or events the circumstances of which might give rise to a claim being made against your Business, its principals, partners, directors, employees or agents alleging medical malpractice, negligence or breach of professional duty in the future?
Yes No
18c. any occurrences, events or investigations the circumstances of which might be the subject of inquiries or proceedings against your Business, its principals, partners, directors, employees or agents for misconduct in the provision of health care services, advice or treatment?
Yes No
18d. any past, current or future inspection, review, inquiry or investigation of your Business, its principals, partners, directors, employees or agents by Medicare Australia, or any allegation of an offence against the Health Insurance Act 1973?
Yes No
18e. any contact by Medicare Australia in relation to your Business, its principals, partners, directors, employees or agents in the last five (5) years?
Yes No
If you answered Yes to any of the above, please provide the following details:
  • Date of incident
  • Date you or any principal, partner, director, employee or agent of your Business became aware of incident
  • Full details of incident, including gender and age of patient (where applicable) but not the patient name or doctor name or any other information which would identity the patient or doctor. If we need patient or doctor names, we will contact you separately.


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: Date of Commencement
Are you registered for GST purposes?
Yes No
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: