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Nurse Insurance :: KlaptonOnline
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Nurse Insurance Application Form
Note: * Indicates required field.

Applicant Information

Requested Third Party and Professional Indemnity Insurance Limits and Deductible

Limit Per Claim* :
Deductible Per Claimant* :

Applicant Information

Insured Information

Use the Applicant's name and address

Insured Business Name

Business and/or corporate name to be included in the Name of Insured.

The policy will show the insured's name, which will include the name of the owner (applicant), the corporate name and trading name. This is in order to provide coverage for your business, as well as yourself.

Professional Information

Choose the group where your practice is listed*. If any of your practices appears in more than one group, choose the higher group (A is lower risk, and C is the highest risk)

A B C
  • Adult Clinical Nurse Specialist Track
  • Clinical Nurse Specialist Track
  • Community Health Nurse
  • Diabetes Educator
  • Enterostomal Therapist (ET) Nurse
  • Nurse Aide
  • Nurse Aide- Working at a facility
  • Nurse Practitioner Adult
  • Nurse Practitioner Family Planning - GYN Only
  • Nurse Practitioner Family Practice
  • Nurse Practitioner Geriatric
  • Nurse Practitioner Paediatric
  • Nurse Practitioner School Nurse (N/A for Midwives)
  • Nurse-Geriatric Nursing Assistant
  • Nursery Nurse
  • Nursing Assistant
  • Nursing Consultant
  • Nursing Management Track
  • Nursing Researcher
  • Nursing Student - (N/A for Midwives)
  • Public Health Nursing Management 
  • Public Health Clinical Nurse Specialist
  • Resgistered Nurse Occupation Health (OHN)
  • RN - Care Manager
  • RN - Case Manager
  • RN - Occupational Health (OHN)
  • RN - School Nurse
  • Advanced Neonatal Nurse Practitioner
  • Clinical Nurse Specialist
  • Nurse Practitioner Neonatal
  • Nurse Practitioner OB/GYN
  • Nurse Practitioner Psychiatric/Mental Health (N/A for Midwives)
  • Private Duty Nurse
  • Private Registered Nurse Psychiatric/Mental Health Nursing Track
  • RN-Recovery Service at Dental Clinics
  • Theatre Nurse
  • Doula (N/A for homebirth)
  • Intensive Care Nurse
  • Nurse Practitioner Acute Critical Care (N/A for Midwives)
  • Self Employed Maternity Nurse (SEMN)

*If your trade does not appear in the list, please refer to our team for a personal quote.

Coverage Extensions

Occurrence Retroactive Date Coverage for the following previous period:

Claim Made Date Coverage for the following future period:

Coverage and include additional professionals/practitioners to this cover:

Coverage and include additional administrative employees to this cover:

Acknowledgement and Declarations

I hereby declare that within the last 5 years:

I had not been revoked, suspended, refused, cancelled or voluntarily surrendered any of the following:

  1. State license, certification or registration
  2. Malpractice insurance
  3. Public liability insurance

No claim or suit for alleged malpractice or public liability has been brought against me and I am not aware of any incident that might reasonably lead to such claim or suit. I have never been convicted (as an adult) of a felony and there isn’t any such case pending. No complaints or charges were brought against me by any licensing board or professional ethics body.

I hereby confirm that I have read and agree with the above statement.

I, the undersigned declare that all answers in this application form are complete and accurate. I understand completely that the answers provided are the basis for the provision of Insurance Cover. Furthermore, I declare that I do not have any supplementary information, in respect of this application, which could influence the outcome of your decision regarding my application request. My signature warrants that my application is submitted in all good faith.

I hereby confirm that I have read and agree with the above statement and it applies both to me and to any additional professional/practitioner and administrative employee included in this application.

Premium Payment Information: I hereby confirm that I understand that after completing and submitting this application form, I must pay the required premium before any cover will become effective.

Submitted Date: 16 Sep 2019