Individuals Professional Indemnity Application

Please complete this application form and we will provide you with a quote for individuals professional indemnity:

Individuals Professional Indemnity Application







eg: Firstname, middle & lastname




Any services other than:
a) Dispensing of medical products prescribed by a medical practitioner.
b) Treatment advice provided by a registered pharmacist where such advice would normally only be provided by virtue of the qualifications of a registered pharmacist.





eg: Victoria 50%, NSW 50% or Queensland 100%

If yes please add details


If yes please add details

If yes please add details

I declare as follows: (1) I am authorised by each of the other Applicants to make this Proposal. (2) I have read and understood the Notice to the Proposed Insured on the front of this Proposal. (3) I have read this Proposal and the accompanying documents and acknowledge the contents of same to be true and complete. (4) I understand that, up until a contract of insurance is entered into, I am under a continuing obligation to immediately inform the insurer of any change in the particulars or statements contained in this Proposal or in the accompanying documents. Although the signing of this Proposal does not bind the Applicants to effect insurance, the Applicants acknowledge that the particulars and statements contained in this Proposal and in the accompanying documents shall be the basis of the contract should a Policy be issued, and further, the Applicants acknowledge that the Proposal and the accompanying documents will be incorporated in the Policy.

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