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Practice Indemnity Quote
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?
*
No
Yes
Number of claims
Total paid by insurer
Do you currently hold practice indemnity?
No
Yes
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
*
Mobile
Email
Preferred time to contact
:
HH
MM
AM
PM
