On-line Individual Malpractice Professional Indemnity Insurance


Thank you for considering our on-line individual malpractice 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 individual malpractice 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. Please enter the full nature of the activities to be covered and type of advice given
4. Medical Qualifications/Graduation Details (degrees, diplomas or college accreditations):
4a. Qualifications:
4b. Year graduated:
4c. Institution and country where graduated:
4d. Year first registered to practise medicine in Australia:
Resume/CV: If not contained on your website, please copy & paste or email your resume.
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:
Medical Board Registrations
6a. Please select the states in which you are registered:
NSW VIC QLD SA WA TAS NT ACT
6b. Have you ever practised under a different name?
Yes No
If Yes, please provide details:
6c. Are any of your Medical Board Registration(s) restricted, qualified or subject to any undertakings?
Yes No
If Yes, please provide details:
6d. Are you currently or have you ever been registered to practise medicine outside Australia?
Yes No
If Yes, please specify each country and name of relevant Medical Board/Registration/Licensing Authority:
6e. Have you ever been charged with or convicted of a criminal offence?
Yes No
If Yes, please provide details:
Category
7a. Category required - area of practice:
7b. Category required - nature of practice:
7c. Do you undertake any procedures/medical services outside of your Category?
Yes No
If Yes, please provide details:
8. Do you practise in more than one Category?
Yes No
If Yes, please provide details:
Category Percentage of
your
Gross Income
%
%
%
%
%
%
Total 100 %
Cosmetic Work
9a. Do you undertake cosmetic procedures that are not listed under the Category you have selected?
Yes No
It is very Important you note: Cosmetic procedures in this context means any procedure directed towards the preservation, correction or improvement of appearance and/or where there are no underlying medical, clinical or pathological reasons for undertaking such procedures.
If Yes, please list all procedures undertaken and an estimate of the Gross Income derived from each procedure:
9b. Do you undertake liposuction procedures of greater than 500mls of aspirate in total?
Yes No
9c. If Yes, are these procedures performed in an accredited day surgery or operating theatre?
Day Surgery Operating Theatre Other
Retroactive Indemnity - Refer Section 2 of the Combined FSG/PDS
10a. Do you require insurance cover for claims that may be made for any incidents that may have occurred in any period prior to your requested commencement date of insurance (Retroactive Indemnity)?
Yes No
If Yes, please complete the following:
10b. Please advise the date from which you require Retroactive Indemnity:
Note: this will mean that if Retroactive Indemnity is granted, you 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 you were aware at the time of this application.
10c. Are your area and scope of practice for which you seek Retroactive Indemnity the same as your existing area and scope of practice? (Answer "No" if, for example, you are now working in Gynaecology only and previously did Obstetrics)
Yes No
If Yes, please provide details in the following table, relative only to the period for which Retroactive Indemnity is required:
Period of Insurance Practice details (eg sole practitioner, partnership, employed by hospital etc) Area(s) of medical practice (ie general surgery) Gross Income/Sessions
From To
$
$
$
$
$
$
Previous Medical Indemnity and Insurance History
11a. Do you currently hold or have you previously held medical indemnity protection or medical indemnity insurance either in or outside Australia?
Yes No
If Yes, please complete the following, listing each individual medical indemnity organisation or insurer:
Period of Insurance/Membership Name of MDO/Insurer Reason for leaving or cancelling Basis of indemnity provided ie. Claims incurred or claims made
From To
11b. Have you ever had a medical indemnity provider or insurer decline a proposal, impose any terms or conditions not contained in its standard wording, cancel or refuse to renew your medical indemnity protection/insurance?
Yes No
If Yes, please provide details:
Cover For Treatment of Public Patients
12a. Do you require medical indemnity insurance for the treatment of public patients (as defined below) where you are not entitled to an indemnity from any other source (including but not limited to a State Government or your Employer) or where you have an option which you are exercising to maintain your own medical indemnity insurance for such work?
Yes No
If Yes, please answer the following questions:
12b. Do you treat public patients in public hospitals?
Yes No
12c. Do you treat public patients in your rooms, in private hospitals or other health care facilities?
Yes No
Public Patient means an individual to whom the Insured provides health care treatment, advice or service under the terms of an agreement with a public hospital (within the meaning of the Health Insurance Act 1973, an area health service or a State or Territory Government, unless the agreement or the billing process has the affect of not classifying the individual as a public patient.
Gross Income
Please advise your estimated Gross Income (as defined below) for the period 1 July 2008 to 30 June 2009 for which you require insurance.
DO NOT record a Gross Income band. A dollar amount is required.
Please Note: Medicare billings represent Gross Income from the treatment of private patients.
13a. Gross Income from treatment of private patients: $
13b. Gross Income from treatment of public patients in public hospitals: $
13c. Gross Income from treatment of public patients in your rooms, in private hospitals or other health care facilities: $
Gross Income means the total of all billings generated by you from all areas of practice for which you require medical indemnity cover for the Policy Period (in your name or for which you are personally liable), including without limitation;
  • Medicare benefits; and
  • payments by individuals, the Commonwealth Department of Veterans Affairs, workers compensation schemes and third party and/or vehicle insurers; and
  • income earned for medical practice overseas that is covered by the Policy whether retained by you or otherwise and before any apportionment of any expenses and/or tax.
If as part of practice, you derive income from any other sources (such as professional fees incentive payments, etc) this income must be included in the declaration of Gross Income.
Sessions
A Session means part of a day not exceeding 6 hours in total.
If you are practising in the following Categories please record the average number of Sessions you work per week for which you require insurance.
  • Cytology
  • Emergency Medicine
  • Medical Officer at Private and/or Public Hospital (not Employer Indemnified)
  • Pathology and/or Laboratory Haematology
  • Radiation Oncology
  • Radiation
14a. For treatment of private patients - Sessions per week:
14b. For treatment of public patients in public hospitals - Sessions per week:
14c. For treatment of public patients in your rooms, in private hospitals or other health care facilities - Sessions per week:
14d. Total Sessions per week:
Interactive Risk management Program
15. Would you like to enrol in the Interactive Risk Management (IRM) Program for 2008/2009?
Yes No
Note: If you elect into PSS you must enrol in the IRM Program
Premium Support Scheme (PSS)
If you elect to participate in the PSS, you must enrol in the IRM Program and achieve 4 IRM points. Details can be found via the Australian Government's website (www.health.gov.au)
16a. Do you want to elect to participate in the Commonwealth PSS?
Yes No
If Yes, please answer all of question 16, otherwise go to Question 17:
16b. Did you apply for and receive a premium contribution under the Medical Indemnity Subsidy Scheme (MISS) prior to 1 July 2004?
MISS may have applied to obstetricians, General Practice Proceduralists (inc GP Obstetrics), Neurosurgeons, General Practice Registrars (undertaking procedural training)
Yes No
16c. Did you practise predominantly in the public sector?
Yes No
16d. Are you a Procedural GP practising in a rural area (RRMA 3-7) as defined by the Department of Health and Ageing?
Yes No
16e. Do you solely provide non-therapeutic services, ie services that are not listed in the General Medical Services table under the Health Insurance Act 1973?
Yes No
16f. Will you be paying premium to another insurer in 2008/2009 year for run-off or retroactive cover?
Yes No
If Yes, please advise total premium (excluding GST and Stamp Duty): $
16g. Do you expect to practise outside Australia for a total of 6 months or more, within the premium period irrespective of whether you require insurance for such work or not?
Yes No
16h. Please record your 8 digit primary Medicare Provider Number:
Your Employees
17a. Do you employ registered medical practitioners, or any other person who provides health care treatment, advice or service charged for and billed in their own name?
Yes No
Note: if yes separate insurance must be effected for each of the above. A separate application form will be required.
17b. Please advise the number of full time (or full time equivalent) staff employed by you or a company or trust owned and controlled by you (excluding registered medical practitioners):
Category of employee Total number of
full time equivalent
employed
Technicians
Midwives
Registered Nurses/Nurse Practitioners
Clerical/administrative
Other allied health professionals (not doctors)
Total
17c. If you employ allied health professional, please detail the category of allied health professionals employed:
17d. Do any of your employees provide services in your Practice that they bill in their own right?
Yes No
If Yes, please provide details:
Note: If you employ individuals in your Practice who bill in their own right, they may not be covered under your medical indemnity insurance.
Extension to Cover
Innocent partner cover
18a. Are you practising in partnership with other medical practitioners who are not insured by Greater National Group?
Yes No
If Yes, you many not be fully protected for your vicarious liability for employees or for joint and several liabilities assumed under such arrangements.
18b. Do you want a quotation for Innocent partner cover?
Yes No
State of Practice
19. Please advise the percentage of your annual Gross Income generated in each State as follows:
NSW  VIC  QLD  SA  WA  TAS  NT  ACT
%  %  %  %  %  %  %  %
Practice Context (Doctors Practising in NSW Only)
20a. Please indicate the average number of hours per week you are engaged in medical practice in New South Wales: hours per week
20b.
Area Estimated Hours Per Week Spent
Public Hospital visiting practitioner appointment
Private Hospital visiting practitioner appointment
Community Health Practice
Private Clinic/Rooms
Licensed Day Procedure Centre Practice
Salaried Medical Officer (Public Hospital) - rights of private practice
College/Society/Association Membership and Fellowships
21a. Please indicate if you are a financial member and/or Fellow of the following:
Member     Fellow
ACEM Australasian College for Emergency Medicine
ACD Australasian College for Dermatologists
ACCRM Australian College of Rural and Remote Medicine
ACCS Australasian College of Cosmetic Surgery
ANZCA Australian & New Zealand College of Anaesthetists
AOA Australian Orthopaedic Association
ASOS Australian Society of Orthopaedic Surgeons
ASPS Australian Society of Plastic Surgeons
NASOG National Association of Specialist Obstetricians and Gynaecologists
RANZCR Royal Australian & New Zealand College of Radiologists
RACGP Royal Australian College of General Practitioners
RACMA Royal Australasian College of Medical Administrators
RACP Royal Australasian College of Physicians (including Paediatrics)
RACS Royal Australasian College of Surgeons
RANZCOG Royal Australian & New Zealand College of Obstetricians and Gynaecologists
RANZCO Royal Australian & New Zealand College of Ophthalmologists
RANZCP Royal Australian & New Zealand College of Psychiatrists
RCPA Royal College of Pathologists of Australasia
SOMANZ Society of Obstetric Medicine of Australia and New Zealand
21b. Are you a member or Fellow of any other College, Medical Association or Society in Australia?
Yes No
If Yes, please specify name of College, Association or Society in full:
Overseas Doctors
22. Are you practising in Australia on a Medical Practitioner Visa 422 or a Temporary Business (Long Stay) - Standard Business Sponsorship Visa 457?
Yes No
If Yes, please attach a copy of your Visa and advise intended departure date:
Run Off Cover
23. Do you intend to retire or cease Private Medical Practice prior to 30 June 2009?
Yes No
If Yes, please advise date:
Note: Private Medical Practice means practice other than treating public patients in public hospitals, practice indemnified by a government or government body or practice outside Australia.
Claims and Circumstances Declaration
24a. Has any:
  • claim for damages, contribution, indemnity or other relief;
  • allegation of a statutory offence (including under the Health Insurance Act 1973; or
  • complaint, proceeding, investigation, examination or inquiry (including by Medicare Australia)
ever been made in connection with the practice of medicine by you, your employees or your practice entity?
Yes No
24b. Has a medical board, medical tribunal or other body ever:
  • made any adverse finding;
  • imposed a suspension, qualification, restriction, condition;
  • terminated a licence or registration to practise;
  • required or accepted an enforceable undertaking; or
  • imposed a fine or penalty
in connection with the practice of medicine by you, your employees or your practice entity?
Yes No
24c. Are you aware of any occurrences or events the circumstances of which might give rise to a matter of the kind referred to in 24a or 24b above?
Yes No
24d. Have you or has any employee in your medical practice been contacted by Medicare Australia or any other party in relation to your billings or income in the last five (5) years?
Yes No
If you answered Yes, to any of the questions above, please provide a detailed description of each matter (including the date of the incident, the date you became aware of the incident and details of the incident including patient name where applicable):


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: