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?
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.
Particulars of Principal:
Resume/CV: If not contained on your website,
please copy & paste or email a brief resume for each Principal and/or
Director.
a.
received / rendered during the last twelve months:
$
b.
estimated for ensuing twelve months:
$
6.
Are any of your operations or clients located outside of Australia
If the answer to the above is Yes , please specify which countries and percentage
of income deriving from each:
7.
Please state the approximate percentage of Your activities (based on income)
applicable to each State, Territory and Overseas.
8.
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:
9.
During past years has any claim been made, or has negligence been alleged
against you or any of the present or former Principals, or have any circumstances
been notified to insurers which may result in a Claims?
10.
Are there any circumstances not already notified to insurers which may give rise
to a Claim against you or any prior corporate practice or any of the present
or former Principals?
11.
Has any principal or staff member ever been subject to Disciplinary Proceedings for professional misconduct?
If the answer to either of the above is "Yes", please provide details below.
a.
Qualified staff-including Principals (please specify professional discipline):
b.
Other technical staff
c.
Non-technical staff (including typists, receptionists etc.)
Total of all staff
13.
Are you or have you or any parent, subsidiary or other related entity either: (i) engaged in, or; (ii) have or had
a controlling share of an entity engaged in:
a.
Actual construction, fabrication, erection or any form of sub contracting?
b.
Real estate development?
c.
The manufacture, sale or distribution of any product or process or patented production process?
If the answer to either of the above is "Yes", please provide details:
(i)
Names of the other entities involved, outlining their relationship to you:
(ii)
Full details, including a description of the nature of the involvement:
14.
State the total number of Full Time Equivalent midwifery placements:
a.
last 12 months
b.
anticipated next 12 months
15.
State the total turnover generated from midwifery placements
a.
last 12 months
$
b.
anticipated next 12 months
$
16.
State the percentage of your total midwifery placements in the last 12 months which were made in:
a.
Private Hospitals
%
b.
Public Hospitals
%
c.
Home Births
%
d.
Other (please provide details)
%
17.
What proportion of your midwifery placements are in:
a.
metropolitan areas?
%
b.
rural areas?
%
c.
remote areas?
%
18.
What proportion of your midwifery placements are in:
a.
hospitals with dedicated obstetric wards?
%
b.
hospitals with general wards only providing birthing facilites?
%
19.
Do you place midwives in hospitals dedicated to high risk pregnancies?
If "Yes" , please provide details:
20.
Are all your placed midwives under the direction of a medical practitioner at all times?
If "Yes" , please provide details:
21.
Do you have a system of independently checking and verifying that all your place midwives are:
a.
tertiary qualified?
b.
registered with the appropriate Nurses Board?
c.
legally licensed to practice midwifery?
22.
After enquiry with all the midwives in your organisation:
a.
Has any Claim been made, or negligence been alleged, against any of the midwives on your register?
If "Yes" , please provide details:
b.
Have any circumstances been reported, which may give rise to a Claim against any of the midwives on your register?
If "Yes" , please provide details:
c.
Have any of the midwives ever been subject to disciplinary proceedings for professional misconduct?
If "Yes" , please provide details:
23.
Do you have a documented system of incident reporting which is adhered to by your placed midwives?
If "Yes" , please provide details:
24.
How are records kept of any incident or Claim reported?
25.
Are the placed midwives:
a.
your employees at all times?
b.
your subcontractors?
c.
independent contractors?
26a.
What limit of indemnity do you require specifically for midwifery placements?
26b.
What is your preferred excess for midwifery placements?
$