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Medical Indemnity Quote
Practitioner Name
Gender
*
Male
Female
Date of birth
*
Address
*
State
Postcode
Speciality
Practice entity name
Do you or will you be hiring staff?
*
No
Yes
Types of staff
Nurses, admin etc.
Total number of staff
Your average no hours worked per week
Private practice hours
Public practice hours
Year you completed fellowship in Australia
Year you first started private Practice in Australia
Have you had any medical indemnity claims in the past?
*
No
Yes
Number of medical indemnity claims
Total paid by insurer
Estimated private billings for next 12 months
Estimated private billings for previous year
Do you do any public patient work which is not indemnified by the hospital?
*
No
Yes
Total public income not indemnified
Do you currently hold medical indemnity?
No
Yes
Insurer name
Due date
Speciality
Total annual premium
What date do you need the insurance policy to commence?
Provide any other information you feel is relevant
Your preferred name
Mobile number
*
Email address
*
Preferred contact method
*
Mobile
Email
Preferred time to contact
:
HH
MM
AM
PM
