Medical Indemnity Quote – Medical and General Risk Solutions

Practitioner Name

Gender*

Date of birth*

Address*

State Postcode

Speciality

Practice entity name

Do you or will you be hiring staff?*

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?*

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?*

Total public income not indemnified

Do you currently hold medical indemnity?

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*

Preferred time to contact

: HH

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