Requested Third Party and Professional Indemnity Insurance Limits and Deductible
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.
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)
*If your trade does not appear in the list, please refer to our team for a personal quote.
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I had not been revoked, suspended, refused, cancelled or voluntarily surrendered any of the following:
- State license, certification or registration
- Malpractice insurance
- 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, 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.
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: 19 Jan 2020