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  • Medical Practice Indemnity Insurance Application

    Everest Medical Indemnity is a registered trading entity of Everest Risk Group Pty Ltd and Corporate Authorised Representative (No 276869) of Insurance Advisernet Australia Pty Ltd (AFSL 240549)
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    Your Privacy

     

    We value your privacy. Our Privacy Policy sets out how we collect, disclose and handle personal information under the Privacy Act and the Australian Privacy Principals. By providing us such information you consent to these practices unless you tell us otherwise. Our Privacy policy is available at https://www.insuranceadviser.net/ia-privacy-policy or by contacting us.

  • YOUR DETAILS


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  • BUSINESS DETAILS

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  • WARNING: THE ABOVE PERCENTAGES MUST EQUAL A TOTAL OF 100%.  

    The current percentage is: {calculation}

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  • FINANCIAL DETAILS

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  • Duty of disclosure

    Before you enter into an insurance contract, you have a duty to tell us anything that you know, or could reasonably be expected to know, which may affect the insurers decision to insure you and on what terms.


    You have this duty until the insurer agrees to insure you.


    You have the same duty before you renew, extend, vary or reinstate an insurance contract.

    You do not need to tell us anything that:

    • reduces the risk we insure you for; or
    • is common knowledge; or
    • we know or should know as an insurer; or
    • we waive your duty to tell us about.

    If you do not tell us something

    If you do not tell us anything you are required to, the insurer may cancel your contract or reduce the amount we will pay you if you make a claim, or both.
    If your failure to tell us is fraudulent, the insurer may refuse to pay a claim and treat the contract as if it never existed.


    Claims made

    This Policy operates on a ‘claims made and notified’ basis. This means that the Policy covers you for claims made against you and notified to us during the
    period of insurance.


    The Policy does not provide cover in relation to:

    1. acts, errors or omissions actually or allegedly committed prior to the retroactive date of the Policy (if such a date is specified);
    2. claims made after the expiry of the period of insurance even though the event giving rise to the claim may have occurred during the period of insurance;
    3. claims notified or arising out of facts or circumstances notified (or which ought reasonably to have been notified) under any previous policy;
    4. claims made, threatened or intimated against you prior to the commencement of the period of insurance;
    5. facts or circumstances of which you first became aware prior to the period of insurance, and which you knew or ought reasonably to have known had
      the potential to give rise to a claim under this Policy; and
    6. claims arising out of circumstances noted on the proposal form for the current period of insurance or on any previous proposal form.

    Where you give notice in writing to us of any facts that might give rise to a claim against you as soon as reasonably practical after you become aware of those facts but before the expiry of the period of insurance, you may have rights under section 40(3) of the Insurance Contracts Act 1984 (Cth) to be indemnified in respect of any claim subsequently made against you arising from those facts notwithstanding that the claim is made after the expiry of the period of insurance. Any such rights arise under the legislation only. The terms of the Policy and the effect of the Policy is that you are not covered for claims made against you after the expiry of the period of insurance.

    Sensitive information

    We have also asked you to provide us with sensitive information about yourself or others insured under this policy, which could include health information,
    criminal history or professional memberships. This information is required because it is relevant to our decision as to whether or not to issue the product
    wish to take out with us and the terms we may issue it to you on.

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  • INSURANCE COVER DETAILS & APPLICATION FOR COVER

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  • Declaration

    I/we declare and agree:

    • that I/we have read and understood my Duty of Disclosure set out during this application and understand that if I do not comply with this duty the Policy may be cancelled or a  claim may be reduced or not paid (or both). If my non-disclosure is fraudulent my Policy may be voided from inception;

    • that I/we have answered every question fully and frankly, have been truthful and accurate in completing this application and have not withheld any information likely to affect the acceptance of this insurance;

    • upon acceptance, this insurance shall be subject to the Medical Malpractice Policy provided with the quotation;

    • that I/we have the consent of all other persons covered by this Policy to provide personal and sensitive information on their behalf;

    • If anything happens during the Period of Insurance which alters any of the information provided, I/we will promptly inform the adviser.

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