Medical Indemnity for Australian Registered Medical Practitioners

Medical Indemnity for Australian Registered Medical Practitioners

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)
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.
Please select one of the following options to request a quick quotation estimate or complete an application for a formal quotation.*
When would you like the policy to commence?

DayMonthYear
Obtain a price indication

If you would like to obtain a price indication please complete the below form and an advisor will contact you within 1 business day.
Name

First NameLast Name
Gender

MaleFemale
Date of Birth

DayMonthYear
Mobile #
E-mail

Confirmation Email
Postcode of Practice
Annual estimated private gross billings
Specialisation 1

AnaesthesiaBarriattric SurgeryCardiology – InterventionalCardiology SurgeryColorectal SurgeryCosmetic ProceduralistDermatologyEmergency MedicineEndocrine SurgeryEndocrinologyGastroenterologyGeneral PhysicianGeneral Practice – Non-ProceduralGeneral Practice — Minor Cosmetics And Skin CancerGeneral Practice — ObstetricsGeneral SurgeryGeneticsGeriatric MedicineGynaecology/IVFHaematologyHospital Medical OfficerImmunology & AllergyInfectious DiseasesIntensive CareMedico-LegalNephrologyNeurologyNeurosurgeryNuclear MedicineObstetrics & GynaecologyOccupational MedicineOncologyOphthalmology – Non-ProceduralOphthalmology – ProceduralOral & Maxillofacial SurgeryOrthopaedic Surgery – Excluding Neck or SpineOrthopaedic Surgery — Incl. Spinal And NeckOtolaryngology (Surgery)Paediatric SurgeryPaediatricsPain ManagementPalliative CarePathologyPharmacologyPlastic & Reconstructive SurgeryPlastic, Reconstructive & Cosmetic SurgeryPsychiatryPublic & Community HealthRadiation OncologyRadiologyRehabilitationRespiratory MedicineRheumatologySports MedicineSurgical AssistingUltrasound – DiagnosticUrologyVascular SurgeryOther
Estimated Private Billings for current financial year (in $)
Add Additional Healthcare Specialisation
Specialisation 2

AnaesthesiaBarriattric SurgeryCardiology – InterventionalCardiology SurgeryColorectal SurgeryCosmetic ProceduralistDermatologyEmergency MedicineEndocrine SurgeryEndocrinologyGastroenterologyGeneral PhysicianGeneral Practice – Non-ProceduralGeneral Practice — Minor Cosmetics And Skin CancerGeneral Practice — ObstetricsGeneral SurgeryGeneticsGeriatric MedicineGynaecology/IVFHaematologyHospital Medical OfficerImmunology & AllergyInfectious DiseasesIntensive CareMedico-LegalNephrologyNeurologyNeurosurgeryNuclear MedicineObstetrics & GynaecologyOccupational MedicineOncologyOphthalmology – Non-ProceduralOphthalmology – ProceduralOral & Maxillofacial SurgeryOrthopaedic Surgery – Excluding Neck or SpineOrthopaedic Surgery — Incl. Spinal And NeckOtolaryngology (Surgery)Paediatric SurgeryPaediatricsPain ManagementPalliative CarePathologyPharmacologyPlastic & Reconstructive SurgeryPlastic, Reconstructive & Cosmetic SurgeryPsychiatryPublic & Community HealthRadiation OncologyRadiologyRehabilitationRespiratory MedicineRheumatologySports MedicineSurgical AssistingUltrasound – DiagnosticUrologyVascular SurgeryOther
Estimated Private Billings for current financial year (in $)
Please enter any further specialties and Estimated Annual Private Billings for each
Any other additional information that you may want to provide for an indicative quote:
How did you hear about us?
Current Insurance Details
Current Insurer
Renewal Date

DayMonthYear
Current Annual Premium
Your Details
Name*

PrefixFirst NameLast Name
Gender

MaleFemale
Date of Birth

DayMonthYear
Mobile #
E-mail

Confirmation Email
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Details

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a practice owner?

YesNo

Are you currently in a training program?

YesNo
Registration Details

As you have marked yes above, please provide details
Are you working on a 422, 457, or any other temporary working visa whilst in Australia? (If Yes, please send a copy to team@everestrg.com.au)

YesNo
AHPRA Registration Number
Year First Registered in Australia
Medicare Provider Number
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.

As you have selected "yes" to the above, please provide details for each matter:
Medical Practice Information

Please provide the Healthcare Specialisation you practise in and the gross billings for the last 3 years. At least one specialisation must be provided.

Do NOT record a Gross Billings band. A dollar amount is required for all healthcare billings for which you require insurance cover.

What to include
Gross Annual Billings are the total billings generated by you from all areas of your practice for which you require indemnity from us within the financial year, whether the funds are retained by you or not, and before any apportionment or deduction of expenses and/or tax. This includes work performed in your name or work for which you are personally liable, including but not limited to:
- Medicare benefits
- payments by individuals
- payments by the Commonwealth Department of Veterans’ Affairs, workers’ compensation schemes and third party and/or vehicle insurers
- income received from other healthcare services provided by you such as professional fees, writing articles, incentive payments and overseas work for which we have agreed to extend indemnity under the policy.
What not to include
You do not need to include any billings or income from healthcare services that you provide for which you have access to indemnity from the public hospital’s indemnity scheme or your employer.
Specialisation 1

AnaesthesiaBarriattric SurgeryCardiology – InterventionalCardiology SurgeryColorectal SurgeryCosmetic ProceduralistDermatologyEmergency MedicineEndocrine SurgeryEndocrinologyGastroenterologyGeneral PhysicianGeneral Practice – Non-ProceduralGeneral Practice — Minor Cosmetics And Skin CancerGeneral Practice — ObstetricsGeneral SurgeryGeneticsGeriatric MedicineGynaecology/IVFHaematologyHospital Medical OfficerImmunology & AllergyInfectious DiseasesIntensive CareMedico-LegalNephrologyNeurologyNeurosurgeryNuclear MedicineObstetrics & GynaecologyOccupational MedicineOncologyOphthalmology – Non-ProceduralOphthalmology – ProceduralOral & Maxillofacial SurgeryOrthopaedic Surgery – Excluding Neck or SpineOrthopaedic Surgery — Incl. Spinal And NeckOtolaryngology (Surgery)Paediatric SurgeryPaediatricsPain ManagementPalliative CarePathologyPharmacologyPlastic & Reconstructive SurgeryPlastic, Reconstructive & Cosmetic SurgeryPsychiatryPublic & Community HealthRadiation OncologyRadiologyRehabilitationRespiratory MedicineRheumatologySports MedicineSurgical AssistingUltrasound – DiagnosticUrologyVascular SurgeryOther
Estimated Private Billings for current financial year (in $)
Actual Private Billings for last financial year (in $)
Actual Private Billings for previous financial year (in $)
Add Additional Healthcare Specialisation
Specialisation 2

AnaesthesiaBarriattric SurgeryCardiology – InterventionalCardiology SurgeryColorectal SurgeryCosmetic ProceduralistDermatologyEmergency MedicineEndocrine SurgeryEndocrinologyGastroenterologyGeneral PhysicianGeneral Practice – Non-ProceduralGeneral Practice — Minor Cosmetics And Skin CancerGeneral Practice — ObstetricsGeneral SurgeryGeneticsGeriatric MedicineGynaecology/IVFHaematologyHospital Medical OfficerImmunology & AllergyInfectious DiseasesIntensive CareMedico-LegalNephrologyNeurologyNeurosurgeryNuclear MedicineObstetrics & GynaecologyOccupational MedicineOncologyOphthalmology – Non-ProceduralOphthalmology – ProceduralOral & Maxillofacial SurgeryOrthopaedic Surgery – Excluding Neck or SpineOrthopaedic Surgery — Incl. Spinal And NeckOtolaryngology (Surgery)Paediatric SurgeryPaediatricsPain ManagementPalliative CarePathologyPharmacologyPlastic & Reconstructive SurgeryPlastic, Reconstructive & Cosmetic SurgeryPsychiatryPublic & Community HealthRadiation OncologyRadiologyRehabilitationRespiratory MedicineRheumatologySports MedicineSurgical AssistingUltrasound – DiagnosticUrologyVascular SurgeryOther
Estimated Private Billings for current financial year (in $)
Actual Private Billings for last financial year (in $)
Actual Private Billings for previous financial year (in $)
Please enter any further specialties and Actual Annual Private Billings for each
Average hours worked per week
Years in private practice

As you have selected 'Yes' to the above, please provide details

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.
- I authorise Everest Medical Indemnity to use and disclose my personal information, including my insurance claims history in accordance with the Privacy Statement
Please acknowledge you have read and accept the above*

I acknowledge the above Declaration
Name of Applicant

First NameLast Name
Position of Applicant
(e.g Director on behalf of the Insured)
Please sign below; or, print, sign and return to team@everestrg.com.au

Clear
Should be Empty:

	Qualifications	Institution	Year Obtained	Country
1
2
3
4
5
6

	Yes	No
Have you ever practiced under a different name?
Have you ever been refused registration, been suspended or de-registered in any country (including voluntary relinquishing your registration)?
Have you ever had any conditions, limitations, notations, reprimands or undertakings imposed on your registration in any country (anything that would be considered an adverse decision to having standard registration)?

	Yes	No
Have you ever been involved in an inquiry, investigation, complaint, coronial inquest in relation to your conduct as a provider of healthcare services?
Have you (or a healthcare providing organisation for whom you have worked) ever been involved in any claims, demands, suits or legal actions which have arisen out of your provision of healthcare?
Are you aware of any act, error, omission or circumstance that has arisen from your provision of healthcare services that could or should have been notified under any current or prior insurance policy or other arrangement under which you are or were entitled to indemnification?
Have you ever been charged with, convicted of or found guilty of a criminal offence in any country?
Have you ever self-notified or been the subject of a voluntary notification to AHPRA or any other healthcare registration authority in any country?
Has any adverse action ever been taken against you by an employer, medical board, hospital, health authority, medical college or statutory body in any country?
Is there any circumstance or situation, past or present, which you are aware of or should reasonably be aware of that relates to your provision of healthcare that is likely to give rise to any claim that would be covered under this policy?
Have you ever been involved in any type of employment dispute arising from the provision of healthcare services including those services provided by you to a healthcare providing organisation or services provided to you by an employee or contractor?
Has any application for or renewal of medical or professional indemnity insurance ever been declined or cancelled, had a loading, deductible or special condition placed on your policy or have you ever been provided a policy with a reduced level of cover?
Have you ever provided healthcare without medical indemnity insurance in place (your own or a policy under which you were entitled to cover) or declined to take run-off cover for a period(s) where you were not practicing?

	Yes	No
Do you undertake any procedures/medical services usually considered to be outside of your specialisation?
Do you intend to practice in numerous Healthcare Services specialisations in the next 12 months?
Do you currently, or have you ever performed cosmetic procedures or obstetrics that are not listed under the Healthcare Services specialisation(s) you have selected?
Do you require medical indemnity insurance for the provision of healthcare to public patients where you are not entitled to indemnity from any other source? (Select "No" if you are indemnified by your employer, public hospital or other third party.)
Have you ever practiced in another specialisation in the last 5 years?

	Percentage
VIC
NSW
SA
WA
NT
QLD
TAS
ACT

	College	Year Fellowship Obtained
1
2
3
4
5