Practice Indemnity Quote – Medical and General Risk Solutions

Practice Name

Trading Name

Your website address

ABN*

Main practice address*

State Postcode

Describe your practice

e.g. GP clinic, Radiology practice, Obstetric practice

When did/will the practice commence trading?

What services/procedures do you perform in the rooms?

Estimated gross revenue next 12 months?

Estimated gross revenue for previous year?

How many doctors work in your practice?

Owners / Directors

Employees

Independent contractors

Room rental

How many staff do you employ?

Admin/Management staff

Healthcare staff

Has the practice had any practice indemnity claims in the past?*

Number of claims

Total paid by insurer

Do you currently hold practice indemnity?

Insurer name

Due date

Retroactive Date

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*

Preferred time to contact

: HH

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